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: ………………………………………