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 illness Back problems Other musculoskeletal problems Cold/cough/flu-influenza Asthma Chest and respiratory problems Headache/migraine Benign and malignant tumours, cancer Blood disorders Heart, cardiac and circulatory problems Burns, poisoning, frostbite, hypothermia
Ear, nose and throat (ENT) Dental and oral problems Eye problems Endocrine/glandular problems Infectious diseases Injury, fracture Nervous system disorders Pregnancy related disorders Skin disorders Substance abuse
Notes: A copy of this form must be kept on the personnel file