You can get a copy of this form by clicking HERE. If this link doesn’t work for any reason, just copy this onto a Word Document and print it off:

Self-Certification Form

Note: This form should be completed on your return to work following any period of sickness of 7 calendar days or less and handed to your immediate superior. If you are returning to work after a sickness absence of more than 7 days, you should provide a Medical Certificate to your immediate superior.

Employee’s Full Name:

Date of sickness (including non-working days)
From: ………/………/………

To: ………/………/………

Date of absence
From: ………/………. /……….

To: ………/………/………

Did you inform the Company on your first day of sickness/absence?
Yes / No

If yes, to whom did you report this information?

Details of sickness or injury:

Did you consult a medical practitioner? Yes / No

If yes, please give details of doctor’s name, address, date of visit, treatment received and any current Treatment

DECLARATION
I certify that I have been incapable of work because of my sickness/injury on the dates shown above and that this information is true and accurate.
I acknowledge that false information will result in disciplinary action.
I hereby give my employer permission to verify the above information.

Employee Signature: ……………………….………

Employer Signature: ………………………………………

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