SELF CERTIFICATE FOR ABSENCE [Due to Sickness/injury/Medical Appointment] AFALSE DECLARATION MAY BE GROUNDS FOR DISCIPLINARY ACTION. Emp No: Name: Business Unit: Location: PERIOD OF ABSENCE Last Day of First Day of Absence ‘Absence Length of Absence days _| Sickness Medical Appointment Absence Details (defails such as “illness” or “unwell” are not sufficient) If your absence was due to Sickness or Injury, please complete the remainder of the form: 1 Did your period of sickness commence during a weekend, rest day, | ya. No holiday or on any other non-working da 2. | Were you confined to your home during your sickness? Yes No 3. Did you consult a Doctor? Yes No 4. | If*yes” please give: | Doctors Name: Tel No: Date and Time of Visit/Telephone Call Did you obtain a Sickness Certificate? Yes No Brief details of advice given: 5. if you did not consult a Doctor, please state “ reason: 6, _| Afe you currently taking medication or undergoing any form of Ye No treatment (resulting from your sickness? es If "yes" have you been informed that this is likely to affect your | y.5 No performance at work or be a safety hazard? If "yes" please specify: The above information is true and accurate in every respect. | understand and accept that the provision of false information would be a breach of trust sufficient to allow Bylor Services to take disciplinary action. | hereby give Bylor Services permission to contact my Doctor to verify the above where ‘appropriate (subject to Bylor Services complying with the provision of the Access to Medical Reports Act 1988). Employees Signature’ Date’ Line Manager's Signature: Date: IMaW}Sick Cert Jan 18