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Illness self-certificate
Name: | Department: | |||||||
Job title: | Clock/Payroll no: | |||||||
A |
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Date and time illness began:
(including non-working days) |
Date fit for work:
(including non-working days) |
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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):
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Signed: | Date: | |||||||