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 Illness Details First & Last Name Email Address Employee Reference Work Number Brief description of your illness: Date of first day of absence (due to sickness): Who did you originally inform of your first day of absence? Date returned to work: Number of days away from work owing to sickness Was your sickness caused by an incident at work? Was your sickness caused by an incident at work? Yes No If Yes, please provide brief details of the incident: Did you consult a doctor? (Yes/No) Did you consult a doctor? (Yes/No) Yes No Have you provided a doctors note? (required for sickness over 7 calendar days) - if YES, please email form to hr@kernock.co.uk Sign & Date Sign & Date Your Signature (Type in this box) Today’s Date (xx/xx/xxxx) Submit This Form
+44 (0) 1579 350561
+44 (0) 1579 350561