Self-Certification of Sickness Absence (SSP)
Complete this form to self-certify your sickness absence and provide statutory sick pay details. Please complete this form for the 1st week of sickness. A Fitness for Work form from your doctor will be required for the 2nd week onwards.
Full Name
*
First Name
Last Name
Job Title
*
First day of sickness absence
*
-
Day
-
Month
Year
Date
Last day of sickness absence
*
-
Day
-
Month
Year
Date
Date of return to work (If known)
-
Day
-
Month
Year
Date
Reason for absence
*
Have you received Statutory Sick Pay (SSP) for this absence?
*
Yes
No
Signature
*
Submit Self-Certification
Submit Self-Certification
Should be Empty: