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.
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