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Self certification of incapacity to


work form
EMPLOYEE TO COMPLETE ON RETURN FROM ABSENCE DUE TO SICKNESS
Personnel Number

2050245

Name

CARMEN LEZAU

Company

BBC WORDWILD

Location

BBC WORLDWIDE, W12

Contract/Departme
nt

Payrol/Operation Manager

Reports to

Adam

Absent
from

29
/15

/ 11

To

6
/15

/ 12

Total days of
incapacity*:

* Include every day, even those you were not supposed to be working (eg weekends and
days off). A medical certificate MUST be provided for absences of 8 or more days
(whether or not you were meant to be working on those days) otherwise you will
not be paid for this absence.
x I am fit to return to work on
(date)

7 /

11 /15

OR

I am still absent from


work

The reason for my incapacity is/was (please tick the ONE that best applies)
Asthma / respiratory
problem

Glandular Fever / ME / Viral


Inf.

Skin condition /
dermatitis / psoriasis

Backache

x Headache / Migraine

Stress / depression /
anxiety

Broken / injured limb

x Infectious disease / Rash

Toothache / dental
problem

Cold / flu / sore throat

x Muscular problem

Diabetes

Operation

Ear infection / hearing


problem

Pregnancy related /
complication

Epilepsy

Sickness / nausea /
diarrhoea

x Urinary / kidney
infection
Chronic / debilitating /
potentially terminal
illness

x Other: haemorrhage
etc

The full details of my condition are as follows: (please supply all relevant information)

On 23th November I started having a haemorrhage for 5 days and I as have had two unfortunate
experiences with the NHS this year, I decided it was in my best interest to find and treat its cause
in Romania. I'll briefly describe the above mentioned experiences.
Mitie 2014 |Geographic Extent: Global |Classification: Mitie Confidential - when complete

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In November 2014, I started coughing and as it did not stop after a couple of weeks ,I went to my
GP, who told me I was fine, the cough would disappear, he sent me home with no treatment. I had
the cough for months afterwards and when I had the chance this year April 2015, I went to
Romania and was told I had an untreated bronchitis, which could have seriously affected my
lungs.
In December 2014 and January 2015, I lost my voice 95% and after 2-3 days, I went to the GP,
who, advised me to take Paracetamol, saying it was nothing serious. It did not work. Days later, I
called my GP from Romania, he advised me what antibiotics I could take as it seemed to be an
infection and I got well soon after.
When the haemorrhage started for 5 days, I knew I had to do some investigations and I decided
to go to Romania, where I could go straight to a specialist without risking to be sent home with no
or useless treatment and wait for it to stop.
If you need more details, please let me know.
Kind regards,
Carmen Lezau

If you do not wish to disclose this information, please tick to


have a confidential discussion with

Your manager

Was your absence due to a work related


No
Yes * on
29 / 11
accident?
(date:)
/
15
* ensure an accident report form is completed and
6/11/15
forwarded
to your manager
Is this an ongoing or recurring problem?

x No

Yes
yet

Not

Did you visit a doctor?

No

x Specialist

Is your job affected by your condition?

No

x Yes

Is your job affected by any medication


you are
taking as a result of this condition?

x No

Yes

x GP

(Please read the


details below)
(Give detail below)

Mitie 2014 |Geographic Extent: Global |Classification: Mitie Confidential - when complete

HR

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If so, was this prescribed?

x By GP

x By
specialist

MG(F)506
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Self
prescribed

Please provide details of how your job is affected:


Not able to stand up and, headaches, dizzy feeling extremely tired, such as loss of feeling
in your arms or legs or movement etc. , having haemorrhage.

I declare that during my absence I am / was incapable of carrying out my normal duties or
engaging in any other work. To the best of my knowledge the information given on this form
is correct and I understand that failure by me to disclose relevant information may
disqualify me from sick pay and lead to disciplinary action against me.
Signed

Date:

MANAGER TO COMPLETE
This
sickness is

Paid

Unpai
d

A return to work
interview took place

No

Yes,
on

/
/

Comme
nt:
Signed
OFFICE
USE

Print
Name
Form
reviewed by

Sickness record
updated?
Outcome
:

Nam
e
Yes

Return to work (no


further action)

Date
Sign
ed

No

Sick note attached?


Referred to GP

Date
Yes
Referred to OH

Mitie 2014 |Geographic Extent: Global |Classification: Mitie Confidential - when complete

No