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Sickness self-certification form

1.Please fill out this form for all sickness absence of between 1 and 7 calendar days (one week, including non-working days).

2.For periods of sickness lasting more than 7 calendar days (including non-working days), please also provide a doctor’s certificate.

3.This form must be completed on the day you return to work. Please submit this form for filing in your employee HR record.

Illness Details

Was your sickness caused by an incident at work?

Did you consult a doctor? (Yes/No)

Sign & Date