Sickness absence notification (Self-certificate) form

Synergy Complex Care > Sickness absence notification (Self-certificate) form

Name

First

Last

Date of absence from

Date of absence to

Reason for absence:

Was the absence due to an accident at work or coming into contact with a notifiable disease? (please tick)

Yes

Declaration: I confirm that the information above is true to the best of my knowledge and that any falsification of the information provided may potentially lead to disciplinary action against me.

Signed

Date

SICKNESS ABSENCE CATEGORIES

Anxiety/stress/depression/other psychiatric illnessBack problemsOther musculoskeletal problemsCold/cough/flu-influenzaAsthmaChest and respiratory problemsHeadache/migraineBenign and malignant tumours, cancerBlood disordersHeart, cardiac and circulatory problemsBurns, poisoning, frostbite, hypothermia

Ear, nose and throat (ENT)Dental and oral problemsEye problemsEndocrine/glandular problemsInfectious diseasesInjury, fractureNervous system disordersPregnancy related disordersSkin disordersSubstance abuse

Notes: A copy of this form must be kept on the personnel file

This field should be left blank