(112) Self Certification Absence Form

SELF CERTIFICATION ABSENCE FORM

A FALSE SICKNESS DECLARATION CAN BE AN OFFENCE UNDER THE RELEVANT STATUTE

Name:*

First NameSurname

Payroll ID (if Known)

Department

PERIOD OF ABSENCE

Date of 1st Day of Absence*

DayMonthYear

Date fit to Resume Work*

DayMonthYear

DETAILS OF ABSENCE

Reason For Absence*

SicknessOther

I was unfit to attend work for the following reason:*

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RETURN TO WORK QUESTIONAIRE

If your absence was due to sickness or injury, please complete the remainder of the form.

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Were you confined to your home during your sickness?

YesNo

Have you Consulted a Doctor, Dentist or did you Attend Hospital?

YesNo

If YES, Please give:

Name of Dr / Dentist etc.Tel No

Date & Time of your Vistit or Telephone call:

DayMonthYearHourMinutes

Are you currently taking or undergoing any form of medication?

YesNo

If YES, have you been informed that this is likely to affect your performance at work, or be a safety hazard?

Specify:

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Any comments you wish to make

The above information is true and accurate in every respect. I understand and accept that the provision of false information would be a breach of trust, sufficient to allow my employer to take disciplinary action which may in certain circumstances lead to my dismissal. I hereby give my employer permission to contact my Doctor to verify the above where appropriate (subject to my employer complying with the provisions of the Access to Medical Reports Act 1988.) I consent, under data Protection legislation, to the Company processing the information I have provided on this form for the purpose of absence recording and monitoring and I understand it will be retained for as long as is necessary to enable the Company to comply with its statute obligations.

Signature

Electronic Signatue

Please Type Your Name

Date*

DayMonthYear