Sickness | Bryher Court Nursing

SICKNESS SELF CERTIFICATION FORM

TO BE COMPLETED BY EMPLOYEE IMMEDIATELY UPON RETURNING TO WORK

You must complete this certificate for all absences of a day or more upto a maximum of seven days due to sickness or injury; periods longer than seven days must be supported by a Doctor’s Fit Note

First name

Last name

DOB

PAYROLL ID:

NI Number

DETAILS OF SICKNESS/INJURY

Date Sickness began

Date returned to work

Total days absent

Who did you inform

What method was used

Please state briefly why you are/were unfit to work. (words such as illness/sickness are not enough). If the absence is related to an injury, please give brief details of the injury and cause.

Did you consult GP

Did you attend a hospital/clinic/similar place

Please give brief state of their recommendation

DECLARATION I declare that I have not worked during the above notified period of absence and the information given is complete and accurate. I agree that the information included above may be recorded in any way deemed appropriate by Bryher Court Nursing Home for a proper management of the Company and its affairs, consistent with the provisions of current legislation.

Signed

Date