Clergy Sickness Absence Self-Certificate

Diocese of Chelmsford

Clergy Sickness Absence Self-Certificate

Please complete this form if you are unable to perform the duties of your office because of illness for a period of one working day or longer

This form should be returned to Julie Mellish, Finance Manager, Chelmsford Diocesan Board of Finance, 53 New Street, Chelmsford, CM1 1AT. or emailed to

Name
Benefice/Parish

Period of absence

Date illness began (include non working days)
Date fit for work
First notification of illness - give details of who you contacted. This should normally be the Area Dean1
Total number of working days absent from duties (include bank holidays) N.B. from 7th day of sickness a GP fit note is required1

Details of sickness absence

Reason for absence

Details of treatment as appropriate

Give details of any doctor, clinic or hospital that you attended – including name and address

Declaration

I understand that if I provide inaccurate or false information about my absence it may result in disciplinary action.
Signed ………………………………………...... Date …………………

1For further details please see the Sickness Section of the Clergy Handbook (Pg.21)