UNIVERSITY COLLEGE LONDON Sickness Absence Record Form

Appendix A

Name: _________________________________________________________________ Department: ____________________________________________________________ Date of first day of absence: _______________________________________________ If part time date fit to return to work: __________________________________________ (if earlier than the actual date of return) Date of return to work: ___________________________________________________

Nature of illness (please tick one box only)

The Sickness Absence recording categories have been updated with a system developed by collaboration of the Health and Safety Executive with the Institute of Occupational Medicine. This scheme is designed to allow employers to classify in a standardised way the reasons for sickness absence provided by employees.

Code 10 11 12 13 14 15 16 17 18 19 20 21 22

Description Anxiety/stress/depression/ psych illness Back Problems Other (not back) musculoskeletal problem Cold, Cough, Flu - Influenza Asthma Chest & respiratory problems Headache / migraine Benign and malignant tumours, cancers Blood disorders (e.g. anaemia) Heart, cardiac & circulatory problems Burns, poisoning, frostbite, hypothermia Ear, nose, throat (ENT) Dental and oral problems

Code Description 23 Eye problems 24 25 26 27 28 29 30 31 32 98 99 100 Endocrine / gland problems Gastrointestinal problems Genitourinary or gynaecological problems Infectious diseases Injury, fracture Nervous system disorders Pregnancy related disorders Skin disorders Substance Dependency Causes - not elsewhere classified in SA scheme Unknown causes / Not specified Whole day medical appointment

I confirm that the above information is correct and that I am fit and well to return to work:

Signed: ______________________________________ Date: __________________

Send to your manager. The form will be retained in the department.

P.T.O

UNIVERSITY COLLEGE LONDON Sickness Absence Record Form

Appendix A

Back to work Interview

To be completed by the Line Manager Was the sickness absence reporting procedure followed? Is the member of staff fit to return to work? If required (absences of more than 7 calendar days) has the doctors fit note been submitted? Was the absence work related e.g. accident at work or general conditions of work area? Is an Occupational Health referral required? If yes has the staff member given permission? Are any work place adjustments required? YES YES NO NO

YES YES

NO NO

N/A N/A

YES YES YES

NO NO NO

N/A

N/A

If yes, please provide details of what is required, who is to action and a timescale for completion.
__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

Is a risk assessment being requested?

YES

NO

N/A

Date of meeting: ___________________________________________________ Name of Line Manager: ___________________________________________ Signature: ______________________________________________________

Signature of member of staff: ________________________________________ Actioned on MyView on by

Please ensure both sides of this form are completed

Updated November 2011

Send to your manager. The form will be retained in the department.