| Source: XpertHR P&D |
|
Date: 19/12/2004 |
Publisher: XpertHR |
Sickness and sick pay: Self-certificate form for sickness absence (form)
TOPICS:| terms, conditions and employee rights | working time and leave
| | contracts of employment | terms of employment
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AUTHOR: David Smellie and Lynda Macdonald
Form wording:
Please read the rules and procedures set out in our sickness absence policy
before completing and returning this form to the human resources
department.
| Name |
|
| Department |
|
| First day I was unfit for work (including weekends) |
|
| First day I was absent from work |
|
| Date on which I was fit to return to work (including weekends) |
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| Date on which I returned to work |
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| My absence was caused by the following illness/injury |
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| If an injury, specify how it occurred, eg motor accident |
|
| I have sought medical advice |
Yes |
No |
| I have consulted my doctor |
Yes |
No |
| I have visited a hospital or clinic |
Yes |
No |
| Employee's signature |
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| Manager's signature |
|
| Date |
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When to use this document
Use this document when an employee has been
absent from work for seven days or less. |
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