Model Forms and Procedures provided by The Employment Adviceline
CERTIFICATE OF ABSENCE FROM WORK DUE TO ILLNESS OR INJURY (SELF-CERTIFICATION FORM)
In order to receive any payment, Statutory or otherwise, for absence due to illness or injury, you must complete this form on the day of your return to work. The Company must be satisfied that your absence was due to illness or injury and that you are fit to return to work. Absence which exceeds 7 days must be supported by doctor’s medical certificates, which must be sent to the Company on a regular basis until you are certified fit to return to work. |
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| Your name | |
| First full day of absence | (day and date) |
| First day of return | (day and date) |
| Reason for absence (please describe symptoms) |
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Did you visit (i) your doctor? (ii) hospital? (iii) clinic? |
Yes / No |
Did you receive medication from:
(i) your doctor? (ii) self-prescribed from chemist? |
Yes / No Yes / No |
| Name of person who was initially notified of absence | |
I understand that if I knowingly provide false information on this form it will be regarded as gross misconduct |
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| Signed | Date |
This section is to be countersigned by the manager, after discussion with the employee, to confirm agreement to the above details.
Manager's comments
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| Signed by manager | Date: |
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