Sickness Self-Certificate

This form is to be used on return to work following any period of incapacity. If this period extends beyond 7 days (including weekends, etc.) you must also provide a medical statement from your Doctor.

Full Name

First

Last

Email

Department

What were the first and last dates on which you were incapable of working, regardless of whether these were working days?

From:

Date

Time

To:

Date

Time

Number of days off work

to incapacity? of

What was the nature of your incapacity, i.e. the name of your illness or the symptoms of your incapacity?

What steps did you take to alleviate your incapacity, e.g. any medication taken, visit to your Doctor, etc?

Please upload doctor's sick note or statement if you have one.

Drag & Drop Files, Choose Files to Upload

Declaration

I confirm that to the best of my knowledge and belief, the above information is correct and that I was absent from work for the reason stated. I understand that my employer may take steps to verify this information and that giving false information is a disciplinary offence.

Employee's Signature

Clear Signature

Date