Stotement of Fitness far Work Doto from poge 1 of this form moy be collected to leorn obovt notionol potterns

For sodai security or Stotutory Sick Poy of sickness obsence Jndividuols wdl not be identified. Find out more ot
www.gov.uk/dwp/fit-note-doto
Potient's nome �r, M<¼,Mlss; M¼ Roman Sali Help getting bod< to work if you ore employed
I onessed your cose on: �2 / 03 / 2024 j Jf you 've been off work or ore likety to be off work sick for 4 weeks or more,
you moy be oble to hove o free occupotionol heolth ossessment. You will be oble
ond, becouse of lhe - to discuss whot odv1ce ond support you need to help you go bock to work sooner.
Pa,n ,n upper Arm
following conditlon(s): You con osk your GP or employer to refer you. For further 1nformotion
• in Englond ond Woles visil www.fitforwork.org or phone 0800 032 6235
• in Scotlond pleose visit www.fitforworkscotlond.scot or phone 0800 019 2211.
Whot your doctor's odvice meons
I odvise you thot 0 )0\1 ore noi fil 'or work 'You ore not fit for work': Your heolth condition meons thot you moy not be oble
o �•�«l<-WOÀ--l•lwJWt0«-\-4-
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to work for the per,od shown. You con go bock to work os soon os you feel oble to
ond, with your employer's ogreement, this moy be before yolX fit note runs out.
lf 0110iloble, and with your emplayer's agreement, you may benefit from: 'You moy be fit for work': You could go bock to work with the support of your
employer Sometimes your employer connot give you the support you need ond if
o o this hoppens your employer will treot this form os though you ore ·not fit for work'.
o You don't need lo get onother of lhese forms from your doctor
�-'-•"41>wo,... -�U\lff

I llll-8-Mù'!i> [l �plt!Ee-odepk>\oOM- For more informotion pleose visil www.gov.uk ond type 'polients ond employees'
Camments, including functlonal efferts of your canditionls): inlo lhe seorch field
sldc noie lor 2 weeks Fili in lhe Your detoils seclion. You con osk someone to do thiS for you if you
connot fdl in your detoils yourself.
--------
Vour detoils - Pleose use BLOCK CAPITALS
Surnome ��Miss, M;. Sah
Other nomes [Roman
Address
rAal 35 Westtey Road, Acocks green Bummgham

This will be the case for

-Blrmtngham.England Poslcode B27 7UO

■·.· . .
ar fram 1 12 I 03 I 202::=] to 24 I 03 I 2024] Dote of birth I 01 , 01 , 1998 ] Mobile [ 07882304415 I
I willlwill nat need ta aness your fitness far wark ogoin at the end of this per iod. NI number
(Plcost' dcictc os opplicoblc} [I] [I] [I] [I] □ ----
Ooctor's nome Whot you need to do now
HAl.'EEO, Amma (Or) • If you ore employed: Pleose show this form to your employer. You could gel
Stotutory Sick Poy (SSP) which is poid by your employer I f your employer connot
poy you SSP lhey wlll 9Ive you form SSPl lo cloim benefits.
�
Oate af stotement 12 I 03 I 2024
• If you ore se lf-employed: You could doim benefits.
Doctor's oddress • If you ore olreody cloiming benefits: Pleose send lhis form to lhe office deohng
I ACOCKS GREEN MEOICAL CENTRE I wilh your doim.
999 Warwtek Road, Acocks Green
81rmingham, B27 6OJ • If you need to moke o cloim to benefits: Visit www.gov.uk/browse/benefits or
Telephone: 01217060501 phone 0800 055 6688 (8am lo 6pm Mondoy lo Fridoy). Textphone users coll
1 I •. ; 0800 023 4888.
1

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