Return to Work / Self Certification form

Employee Name: NAME Team Leader: MANAGER

Staff who are absent from work through ill health must complete this form immediately upon return to work and submit
it to their line manager. For absences over 7 days (including weekends) a doctor’s certificate is required.

Sickness absence information is held electrically and will be processed in accordance within the Data Protection Act
1998. The data will be used for statistical analysis in an anonymous form, and also made available to your team
leader to help meet the Company’s obligation to ensure the health, safety and welfare at work of all employees.

Number of absences in last 12 X periods of Total number of days absent in the X days
months absence last 12 months
First day of sickness: DD/MM/YY Total number of working days X days
absent
Last day of sickness: DD/MM/YY Doctor’s certificate attached Y/N
If absence exceeds 7 days
Reasons for absence (please also describe symptoms)
e.g. Virus – headaches, upset stomach, and fever

Who did you report your sickness to and when?

Are you fully fit to return to work? Was your absence work related/accident at work? Yes / No
If yes, please provide details
Yes / No

Was your illness related to an ongoing medical condition: Yes / No

If yes, please provide details

Any adjustments to workplace/hours/duties to facilitate return to work? Yes / No

If yes, please provide details

Details of treatment
Did you seek medical advice?
Please provide details
If yes, please provide details:

Please state any medication prescribed:

Self-prescribed treatment:

I understand that if I provide inaccurate or false information about my absence it may, depending on the
circumstances, be treated as gross misconduct and dealt with under the disciplinary policy. I hereby give
my employer permission to contact my doctor to verify the above information where appropriate.
Employee’s Date:
signature:
Manager’s Date
signature:

Sick Pay Type: UNPAID (SSP) / HALF PAY / FULL PAY

*Delete as appropriate