Notification of Absence Form
Private & Confidential
You much complete this form for all absences of 7 calendar days or less. Please note absences in excess of 7 days will require certification from your G.P. If this form is not completed, you may lose any entitlements you have to payments for your absence. To give false information may render you liable to disciplinary action. You may be required at any time to present yourself to Occupational Health for a medical assessment/examination to be arranged by the company. PLEASE NOTE YOU MUST REPORT YOUR ABSENCE VIA TELEPHONE TO THE NURSE IN CHARGE AND NOT VIA TEXT MESSAGE. If applicable, a follow up call will be made on receipt of this notification.
Employee Name:
*
First Name
Last Name
On what date did your absence start
*
-
Day
-
Month
Year
Date
Time your absence started
*
Hour Minutes
Who did you report your absence to THIS MUST BE THE NURSE IN CHARGE AND VIA TELEPHONE NOT TEXT MESSAGE
*
Reason for absence
*
Is the absence the result of an accident at work?
*
Please Select
Yes
No
Is this absence related to a disability or impairment?
*
Please Select
Yes
No
Signature:
*
Date:
*
-
Day
-
Month
Year
Date
Submit
Should be Empty: