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Sickness Absence Self-Certification Form Template

Sickness and Absence Self-Certification Form


This Absence Self-Certification Form should be filled in by the employee to provide details of any sickness absence to their employer. The Absence Self-certification Form incorporates a section for the purpose of stating whether the absence was related to a disability under the Equality Act 2010. This is in order to make it easier for the employer to distinguish between general absence or illness and disability related absence, and so avoid any unintentional discrimination that may otherwise occur.

This Absence Self-Certification Form includes the 'fit note' requirements.

This form is used during periods of Sickness Absence as stated by the requirements of the Sickness and Absence Policy. It is important that the completed form indicates actual days of Sickness, even if they include days when you would not normally have worked (e.g. weekends and public holidays).

The Company may conduct a return to work interview to discuss Absence and Illness.

The Sickness Self-Certification form should be completed for Sickness Absence of up to 7 calendar days.

Under normal circumstances, Sickness Absence of more than 7 calendar days requires a Medical Certificate. Subsequent Medical Certificates must be produced as necessary to cover the total duration of the Period of Absence.

This form template is in fixed field format. Simply press TAB to jump from one field to the next and SHIFT + TAB to go back. Alternatively, use the mouse to click from one field to the next.

If you are using Microsoft Office 2003 or older, the template can be unlocked by clicking on the “Padlock” icon on the tool bar. To display the “Padlock” icon click on “View” and then “Toolbars”. From the “Toolbars” menu, select “Forms”.

Users of Microsoft Office 2007 must first click on the “Review” tab to reveal the “Protect Document” button. From the “Permissions” panel that opens, click on the “Stop Protection” button.

Once you have subscribed to the appropriate document folder click on the “Download Document” button below. You will be asked what you want to do with the file. It is recommended that you save the document to a location of your choice prior to viewing.

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