Fill and Sign the Record Absence Form

Record of Absence/ Self-Certification Form This form should be completed for all periods of sickness absence. If the absence is for less than 7 days the form can be completed upon return to work. However, if the absence continues for longer, the form should be sent to the employee to complete, or be completed by the line manager and confirmed by the employee at the earliest opportunity. To be completed by the employee: Employee Name:       Payroll Number:       Service:       Job Title:       I certify that I was absent from work due to sickness during the period stated below: Date sickness started:       Date sickness absence ended:       Number of working days absent:       (for absence monitoring purposes) My reason for absence was as follows (please check appropriate check box): Viral Infection Eye, Ear, Nose and Mouth Dental Stress/depression/Mental Health/ Fatigue Syndrome (anxiety, nervous debility/disorder) Work Related Stress Migraine/Headache Cold/Flu (including coughs, throat infections, etc,) Chest, Respiratory (for example asthma, bronchitis, hayfever) Heart, Blood Pressure, Circulation Neurological illness (epilepsy, motor neuron disease) Stomach, Liver, Kidney & Digestion (diarrhea, vomiting, and stomach upset) Back Problems Other Muscular Skeletal Disorders (neck, legs, feet, arms, or hands; also joint problems such as arthritis) Critical Illness (cancer, major organ transplant, stroke etc) Surgery Related Absence Accident at Work Accident outside work Other reasons for absence       Notification of Illness If for any reason you are unable to come to work due to ill health, you must notify your manager giving the reason as quickly as possible on that day. Immediate notification is important and delay could jeopardize your pay entitlement. If your absence continues after the third working day you must contact your manager as to the nature and possible duration of your illness. This form is to be completed on your first day of return to work. A medical certificate must be obtained and sent immediately to your manager if your sickness lasts more than 7 calendar days. For all such absences you will be required to complete this form in respect of the first 7 days either during your absence (in which case the form will be sent to you) or on your return to work. PURPOSE The purpose of keeping sickness absence records is to monitor overall sickness absence trends across the company (without identifying individual cases) and to enable line managers to monitor individual absence levels/trends, discussing with and supporting employees if issues are identified. All records are kept confidentially and access to them restricted. DECLARATION I declare the reasons shown for my absence and the information given on this form is correct, to the best of my knowledge. I understand that making a false statement may result in disciplinary action being taken and sick pay being terminated. Signature Date       b) To be completed by the manager I certify that I have:  Discussed this absence with the employee  Ensured that the necessary certifications are completed and retained by me  Ensured that the information is passed to Human Resources Signature of Manager Date