Sickness Absence-Self Cert 2003/HR/Templates
SICKNESS ABSENCE SELF-CERTIFICATE
Self certification is required for ALL periods of absence up to and including seven days, after
which a doctor’s medical certificate will be required.
PRIVATE & CONFIDENTIAL
PLEASE USE BLOCK LETTERS
TITLE & FULL NAME: ……………………………………………………………………………….
SCHOOL/DEPARTMENT OR SECTION: ...........................................................................
JOB TITLE: .........................................................................................................................
PERIOD OF SICKNESS
First day of absence: .........................................................................................................
Last day of absence: .........................................................................................................
Date of return to work: .......................................................................................................
DETAILS OF SICKNESS/INJURY
I was unfit to attend for work for the following reason:
(Please be specific e.g. influenza, rheumatism, injury at work etc. It is not acceptable to state
“sick” or unwell”)
..............................................................................................................................................
DECLARATION
I declare that I have not worked during the period of sickness stated above and that the
information given is factually correct.
EMPLOYEE'S SIGNATURE: ..............................................................................................
DATE: ..................................................................................................................................
HEAD OF SCHOOL/SECTION SIGNATURE: ....................................................................
DATE: ..................................................................................................................................
N.B. The completed form should be returned to Human Resources, Lord Balerno Building
Resume Templates 1210 Document(s)
