Employee Statement of Sickness – Confidential

(Copy to be retained on supervision file)

Employee No: / Name: / Dept:

Sickness notified/record of contact:

Date: / Time: / Details (continue on a separate sheet, if necessary): / Message taken by:
First Day Sick: / / / / Last Day Sick: / / / / Reason:

Was the absence (delete as appropriate):

§  Due to an accident at work? YES / NO If YES, accident No: ______

§  Pregnancy related? YES / NO

§  Disability related? YES / NO If YES, what is the disability?: ______

§  Did the absence last for more than 7 calendar days (not just working days)? YES / NO

§  If YES, was a medical (doctor’s) certificate provided from 8th day of absence? YES / NO

§  If YES, it is attached to this form / it has been sent to HR on ______(delete as appropriate)

(date)

Previous sickness record (not including this sickness):

In last 12 (rolling) months: / days in / instances.
Summary of return to work discussion (e.g. frequency, cause, treatment, previous absences etc):
Future actions (e.g. monitor absence levels, occupational health referral, disciplinary action etc):
Has Initial Review Period been confirmed? YES / NO (delete as appropriate) If “No”, Occupational Sick Pay cannot be authorised.
If “Yes” , subject to organisational policy Occupational Sick Pay is / is not approved because (delete as appropriate):
Signature: / Name: / Date:
Line Manager / Line Manager

Employee Statement: I confirm that the information given above is true and complete. I give my permission for a record of my sickness to be maintained and understand that without appropriate certification no payments can be considered. I confirm that I have read and understand the Sickness Absence Policy.

Signature: / Name: / Date:
Employee / Employee

Please note:

If more than 7 days or 3 instances in last 12 months (not including this sickness), 2nd Line Manager’s authorisation is required.

I approve / do not approve the above decision (delete as appropriate). If not approved, please outline your reasons:
Signature: / Name: / Date:
2nd Line Manager / 2nd Line Manager

HR use only: