Employee Sickness - Self Certification

Employee Sickness - Self Certification
In accordance with Hashtag Clean’s absence management and reporting policy, employees are required to complete this form for all sickness absence of seven calendar days or fewer. (For periods of sickness lasting more than seven calendar days, employees should provide a doctor’s certificate/fit note.)

Please complete this form on the day that you return to work.
Name

First NameLast Name
Job title
First day of absence

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Last day of absence

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Brief description/reason for absence
Person notified of absence
Number of days away from work owing to absence (excluding regular non-working days)
Was your sickness caused by an accident at work? If so, give brief details:
Your signature
Todays date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Should be Empty: