Sickness - Self Certification FormSICKNESS SELF-CERTIFICATION FORM
This form is required to certify periods of continuous absence, due to illness or injury, of at least 4 working days, but not more than one calendar week, where no doctor's fit note exists to cover this period of absence.
If you are sick for:
1. Between 1-3 working days, this form is not required.
2. Four or more working days, but not more than one calendar week (and you do not have a doctor's fit note to cover this period), please complete this form on your return to work.
3. More than one calendar week,
i) A doctor's fit note is required to certify the period beyond a calendar week.
ii) This form is required to cover the first calendar week of sickness, (in the absence of a doctor's fit note for this period).
iii) You may be required to complete and return this form before you return to work.
For the purpose of calculating your sick pay you are asked to give the first and final days of sickness, even if these days are not working days.
Please complete this form in BLOCK CAPITALS using black ink.
1. Personal Details
SITE/PLACE OF WORK:
2. Period of Sickness
FROM: / /
(First day on which you were sick)
TO: / /
(Final day on which you were sick. If sickness is continuing, seventh consecutive calendar day sick)
3. Details of Sickness
Please provide brief details of the reason for your absence:
Is the absence due to an injury sustained at work? YES | NO
If you answered YES you should also complete an Accident Report Form.
4. Employee Declaration
I declare that the above information is correct and I understand that it will be used in the computation of my sick pay.
I certify that the signatory has completed this certificate, and that the signatory was absent from work for the period shown above.
This completed form should be returned to [Insert person and their position].