Staff Self Certification

THIS FORM SHOULD BE USED FOR
For all staff to self-certify for absence of 1-5 days inclusive (for 6 days or more, a medical certificate is required)
Yes No
Did you receive medical treatment from your doctor during your absence? If Yes, please give doctor details below *
Do you consider your absence to be as a result of an accident/injury at work? If Yes, report to Line Manager immediately *
Do you consider your absence to be related to a disability/special requirement? *
Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png bmp txt pdf doc docx xls xlsx xml.
Employee Declaration
Submission of this form is the employee's declaration that: <> The information stated is complete and true. <> The illness or incapacity prevented the employee from carrying out normal working duties <> The employee has not engaged in any activity that has delayed their recovery
FOR OFFICE USE ONLY
Approval / action - absence processed (Mrs Z Ball)