Self-certificate Absence Form

"*" indicates required fields

Please only submit this form on the day you return to work, and where the absence is less than 7 days.

Please select an office/region:*

Role of employee who was absent:*

Name of person completing form:*

Name of absent employee:*

Email address:*

Phone number:*

Reason for absence:*

Is the reason for absence an illness involving diarrhoea or vomiting?*

Yes

First day of absence:*

Last day of absence:*

Date of return to work:*

Total time absent: (In days)*

On what date did you notify the Company of your absence?*

Who did you notify?*

How did you notify management?*

Please note that it is against our policy to text or email when informing us of your absence.

Which manager did you speak to over the phone?*

Was your absence due to sickness?*

Yes

Since your absence was due to sickness please complete the following:

Did you consult your doctor?*

Did you obtain a medical certificate?*

Please attach your fit note:*

Accepted file types: jpg, gif, png, jpeg, xlsx, docx, pdf, Max. file size: 50 MB.

The following information is required to ensure the health, safety and welfare at work of yourself and others.

Are you taking any medication?*

Please provide details about the medication you are taking:*

Have you been advised of any side effects that could affect your work or may be a safety hazard?*

Please provide details about the side effects you were advised of:*

Declaration

I declare that all the information I have given in this form is true and that I have not withheld any material fact.

I understand these details will be held in confidence by the Company and may be used for the following purposes in compliance with the Data Protection Act 1998:

Ensuring the health, safety and welfare at work of myself and other workers
The avoidance of discrimination on the grounds of disability
Maintaining SSP and SMP records
Supplying information on accidents where industrial injury benefits may be payable
Ensuring the Company is able to monitor and deal fairly with attendance and absence issues.

Employee name:*

Date:*

Employee signature:*