Self Certification of Sickness Absence

This form is to record sickness absence information and is to be completed by the employee on the first day of return to work and countersigned by their line manager. It must be completed for all periods of sickness absence of half a day or more. if you are sick for more than seven consecutive calendar days, you will require a doctors certificate (called a statement of fitness for work). If you leave work early on a particular day as a result of sickness, you should record the time left in the section headed “date on which you first became unfit for work”.

Honest Crust will process the personal data collected in connection with the operation of this policy in accordance with its data protection policy. Inappropriate access or disclosure of personal data will constitute a data breach and should be reported immediately to the Operations Manager. Reported data breaches will be investigated and may lead to sanctions under our Disciplinary Procedure.

Full Name of Employee

Date on which you became unfit for work:

Date on which you resumed work:

Total number of working days (including half days) absent due to illness:

Please give full details of your illness or injury - 'sick', 'ill' or 'unwell' are insufficient:

Is your illness related to a pre-existing medical condition or disability? If yes, please provide further details:

Did you visit your doctor in relation to this period of illness or injury?

Did you seek other medical advice in relation to this period of illness or injury, for example from NHS Direct? if yes, please state who you sought medical advice from and the method of seeking it:

If you did not visit your doctor or seek other medical advice, please give the reason why not:

Have you sent a doctors cetrificate to theresa@honestcrustsourdoughpizza.com if its been over 7 days?