Sickness Self-Certification Absence Sickness Self-Certification This form should be completed on your return to work following any period of sickness. However you must also comply with any requirement for submission of medical certificates as detailed in your Employee Handbook/Policies and ProceduresName(Required) First Last Email(Required) Sickness Start Date(Required) DD slash MM slash YYYY Sickness End Date(Required) DD slash MM slash YYYY CommentsPlease enter detailsDid you consult a doctor?(Required) Yes No DeclarationI certify that I was incapable of work because of my sickness/injury on the above dates and that this information is true and accurate. I acknowledge that false information may result in disciplinary action. I certify I was incapable of work on the above dates.Signature
