Sickness Self-Certification Form
This form should be completed on your return to work following any period of sickness. If you are returning to work after a period of sickness of more than 7 calendar days a medical certificate should already have been provided to cover the period of absence in excess of these first seven days.
Name
*
First Name
Last Name
First date of absence
*
-
Day
-
Month
Year
Date
Last date of absence
*
-
Day
-
Month
Year
Date
Total number of days absent (for absence monitoring purposes)
*
1
2
3
4
5
6
7
More than 7
Details of sickness (please select one)
*
Musculoskeletal
Chest, respiratory
Colds and flu
Sickness, nausea and diarrhoea
Migrane, headache
Mental ill health
Workplace injury
Sporting injury
Accident outside work
Long-term health condition
Dental
Gynaecological
Other
Please provide details
*
What steps did you take to alleviate your incapacity eg visit to the doctor .
*
Please upload your medical certificate (if you are absent for 7 days or more)
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Declaration: I certify that I was incapable of work because of my sickness/injury on the dates shown above and that this information is true and accurate.
*
I acknowledge that false information will result in disciplinary action and I hereby give my employer permission to verify the above information.
*
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