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Sickness Self-Certification Form

This sickness self-certification form collects information about an employee's recent sickness absence from work. It documents the dates of absence, who was notified, and brief details about the illness. It also asks if the employee attended the hospital or saw a doctor, received any medication, and includes declarations about the accuracy of the information and signatures from the employee, supervisor, HR, and payroll. The form is used to process statutory sick pay and record the sickness absence.

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Cynthia Robinson
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1K views1 page

Sickness Self-Certification Form

This sickness self-certification form collects information about an employee's recent sickness absence from work. It documents the dates of absence, who was notified, and brief details about the illness. It also asks if the employee attended the hospital or saw a doctor, received any medication, and includes declarations about the accuracy of the information and signatures from the employee, supervisor, HR, and payroll. The form is used to process statutory sick pay and record the sickness absence.

Uploaded by

Cynthia Robinson
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

CONFIDENTIAL

SICKNESS SELF CERTIFICATION FORM (This form must be completed for each period of absence)
First Name: Department: .. .. Surname: Personnel No: .. ..

Period of Sickness Absence & Notification Date of first day of sickness absence from work: Date of last day of sickness absence from work: Name of person notified: Absence pattern: Number of hours not worked per day due to sickness: M T W Th F S Su FT / PT

Do you work Full Time or Part Time hours:

Details of Sickness Absence Please give brief details of your illness:

Did you attend hospital your doctor Did you receive medication

Yes/No Yes/No Yes/No

If Yes, give details of hospital/doctor

Declaration I understand that this information will be used as a basis of paying Statutory Sick Pay (SSP)and that any false statement may lead to disciplinary action. Employees Signature: Date:..

Is this employee on their probationary period? Supervisors Signature:.

Yes / No

Paid/Unpaid

Date:...

Signed by HR: Signed by Payroll (if over 4 days):.

Date:. Date:..

SEND FORM TO HUMAN RESOURCES YOUR SICKNESS WILL BE RECORDED.

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