EMPLOYEE’S STATEMENT OF SICKNESS

"*" indicates required fields

Phone

This field is for validation purposes and should be left unchanged.

Full Name*

Title (Mr/Mrs/Miss/Ms/Other title) First Name(s) Surname or Family Name

National Insurance Number*

Date of birth*

Clock or Payroll Number

About your sickness*

Please give brief details

What date did your sickness begin?*

What date did your sickness end?

Is you do not know, please leave this blank.

The days you put in these two boxes may be days you do not normally work. If you are sick for more than seven days, your employer may ask for a medical certificate from your doctor. Medical certificates are also called sick notes or doctor's statements.

What date did you last work before your sickness began?*

What time did you finish work on that date?*

Enter time in 24 hours

Was your sickness caused by an accident at work or an industrial disease?*

If you answered 'Yes', you may be able to get Industrial Injuries Disablement Benefit. If you want information about claiming this benefit, ask at any Jobcentre Plus office.

Signature*

Date*