SICKNESS SELF-CERTIFICATION ABSENCE FORM

"*" indicates required fields

This form should be completed in respect of absence from work due to sickness or injury for up to the first 7 calendar days. Medical Certificate(s) must be provided to cover all absence of more than 7 calendar days.

NAME*

FIRST NAME LAST NAME

DATE*

DATES OF SICKNESS (include non-working days)

TIME (FROM)*

DATE (FROM)*

TIME (TO)*

DATE (TO)*

Working Days of Absence

TIME (FROM)*

DATE (FROM)*

TIME (TO)*

DATE (TO)*

DETAILS OF SICKNESS OR INJURY*

DID YOU CONSULT A MEDICAL PRACTITIONER?*

Yes

IF 'YES', PLEASE GIVE DATE OF VISIT*

TREATMENT RECEIVED AND ANY CONTINUING TREATMENT*

DOCTOR'S NAME

FIRST NAME LAST NAME

DOCTOR'S ADDRESS

FIRST LINE SECOND LINE TOWN/CITY COUNTY POST CODE

WAS THE COMPANY NOTIFIED OF YOUR ABSENCE, AS REQUIRED?*

Yes

IF 'YES', WHO DID YOU NOTIFY?*

IF 'NO', GIVE REASON FOR NOT DOING SO*

Declaration

I certify that the above information is true and I acknowledge that false information will result in disciplinary action. I hereby give my employer permission to verify the above information.

For Absences of Up to 7 Days (where appropriate)

I certify that I have been incapable of work because of my sickness/injury on the dates shown above and that I am now fit to follow my normal duties (this includes the operation of machinery, equipment, driving and working at heights as appropriate).

EMPLOYEE SIGNATURE*

TRANSPORT MANAGER/MANAGING DIRECTOR*

Phone

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