Illness self-certificate

Illness self-certificate

 

Name: Department:
Job title: Clock/Payroll no:

A
Date and time illness began:

(including non-working days)

 Date fit for work:

(including non-working days)
First notification to:

(give method of notification and name of person notified)

 Notification date:
   
B C
Reason for absence: Did you attend:
Hospital: YES/NO
Clinic YES/NO
Your doctor YES/NO
Are there any reasonable adjustments required when you return to work?
I understand that if I provide inaccurate or false information about my absence it may, depending on the circumstances, be treated as gross misconduct and result in my summary dismissal.
Signed: Date:
Supervisor’s remarks (including date of return if known):

 

 
Signed: Date: