Sickness Self-Certification Form

Sickness Self-Certification Form

To be completed by the member of staff returning from a period of absence
Your name*

First NameLast Name
Place of work*
Absent from?*

DayMonthYear
Date
Absent to?*

DayMonthYear
Date
Total days absent?
If a member of staff is off sick for more than 7 days, a doctors note is legally required.
Details of sickness or injury*
Did you consult a medical practitioner or were you admitted into hospital?*

YesNo
Was the reason you were absent from work due to a work-related injury?*

YesNo
I certify that I have been incapable of work because of my sickness/injury on the dates shown above, and this information is true and accurate:*

Yes
Signature*

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By placing your name in this box, you are legally e-signing this document and all information given is true and accurate.
Date*

DayMonthYear
Date
Should be Empty: