Self Certification Of Sickness Form

Self Certification Of Sickness Form
This form is to record sickness absence information and is to be completed by the employee on the first day or return to work. It must be completed for all periods of sickness absence of half a day or more. If you are sick for more than seven consecutive calendar days, you will require a doctor’s certificate (called a statement of fitness for work). If you leave work early on a particular day as a result of sickness, you should record the time you left in the section headed “date on which you first became unfit for work”.

Once completed, this form will be placed on your personnel file and retained for a period of three years.
Name
Date on which you became unfit for work

DayMonthYear
Date on which you resumed work

DayMonthYear
Total number of working days (including half-days) absent due to illness
Please give full details of your illness or injury –‘sick’, ‘ill’ or ‘unwell’ is insufficient
Is your illness related to a pre-existing medical condition or disability?
Please provide further details
Did you visit your doctor in relation to this period of illness or injury
What did the doctor diagnose and medical advice given
If you did not visit your doctor, please give the reason why not
Did you seek other medical advice in relation to this period of illness or injury, for example from NHS Direct
Please state who you sought medical advice from and the method of seeking it
Are you uploading a fit to work note
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Cancelof
I declare the above information to be true and accurate and I confirm that I am now fit to resume work. I understand that it is a serious disciplinary offence to provide false information on this form.
Signature
Date

DayMonthYear
Should be Empty: