Scribd
Upload
87 views2 pages

Self Certification Form

This self-certification form is used by employees to report absences from work of seven days or less. It collects details about the employee, reason for absence, dates missed, and whether a doctor was consulted. The employee signs to confirm accuracy and accepts disciplinary action could occur if providing false information. Managers review the form and use it to facilitate return to work discussions, and store it securely or submit to HR Services.

Uploaded by

Julee Bugayong
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
87 views2 pages

Self Certification Form

This self-certification form is used by employees to report absences from work of seven days or less. It collects details about the employee, reason for absence, dates missed, and whether a doctor was consulted. The employee signs to confirm accuracy and accepts disciplinary action could occur if providing false information. Managers review the form and use it to facilitate return to work discussions, and store it securely or submit to HR Services.

Uploaded by

Julee Bugayong
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

Self-Certification Form

You should complete this form following a period of absence from work. You may self-certify your absence for the
first seven days. If your absence lasted longer than seven consecutive days then you must provide a Fit Note.

Once you have completed it, you should give this form to your manager.

 Employee Details
Employee Name:
Employee Number:
Business/Function:
Job Title:

 Absence Details
Please tick the box which best describes Illness
the reason for your absence from work: Accident which occurred whilst working for The Co-
operative Group
Accident which occurred during other employment
Accident which occurred outside of work
Other
Please provide full details about the reason
for your absence:

Did you consult a doctor or other medical Yes No


practitioner? (If yes, what was the advice
given?)
Are you fit to return to your normal duties? Yes No
(if no, please give details)
Was your absence pregnancy-related? Yes No
(pregnant employees only)
Absence dates: __ / __ / ____ to __ / __ / ____

Start time / Time sent home:


First day of illness (if not the same day):
Number of working days absent:

Self-Certification Form
 Absence Notification
Did you notify your manager on the first day of your Yes No
absence? (if no, please explain why)
Time and date you notified your manager:

If your absence exceeded 7 consecutive days, have


you provided a Fit Note? (if no, please explain why)

 Authorisation
To the best of knowledge the above details are a true and accurate statement and I accept that the deliberate
provision of false information may lead to disciplinary action, up to and including summary dismissal, and
possibly to prosecution by the DWP.

Employee Signature: Date:

Manager Note: Please review this form and use it to inform the Return to Work discussion with the employee.
You should store this completed form locally within a secure location. If you do not have a secure place to
store this form please send a copy to HR Services by emailing [email protected] or by post to HR
Services, 7th Floor, 1 Angel Square, Manchester, M60 0AG.

Self-Certification Form

You might also like