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Sickness Self-Certification Form

This form is for employees to complete upon returning to work after a period of sickness. It requests information about the dates and details of sickness, whether a doctor was consulted, and requires the employee's signature to certify the accuracy of the information provided.

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Daniela Grosu
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1K views1 page

Sickness Self-Certification Form

This form is for employees to complete upon returning to work after a period of sickness. It requests information about the dates and details of sickness, whether a doctor was consulted, and requires the employee's signature to certify the accuracy of the information provided.

Uploaded by

Daniela Grosu
Copyright
© © All Rights Reserved
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

SICKNESS SELF-CERTIFICATION FORM

This form should be completed on your return to work following any period of sickness.
If you are returning to work after a period of sickness of more than 7 calendar days, a medical
certificate or certificates should already have been provided to cover the period of absence in
excess of these first seven days.

Last Name: ………………………………… First Name: ………………………………………

Date of sickness (including non-working days):

[__/__/__] am / pm to [__/__/__] am / pm (Cross out the time of day.)

Date of absence:

[__/__/__] am / pm to [__/__/__] am / pm (Cross out the time of day.)

Details of sickness/injury : ..…………………………………………………………………………


………………………………………………………………………………………………………
……………………………………………………………………………...………………………
Did you consult a Doctor? YES NO
If Yes, please give details of Doctor’s name, address, date of visit, treatment received and
any current treatment. If No, please state why not:
………………………………………………………………………………………………………
……………………………………………….………………………………………………………
…..……………………………………………………………………………………………………

Declaration
I certify that I was incapable of work because my sickness/injury on the dates shown above
and that this information is true and accurate.

I acknowledge that false information will result in disciplinary action.

I hereby give my employer permission to verify the above information.

Date: [__/__/____]

Signature: …………………………

[Link]

ALTEN LTD | 41 Moorgate, London, EC2R 6PP | Company Number 8452862 | VAT GB 163 3959 84|

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