Appendix B
SELF CERTIFICATION FORM (SCF1A)
PERSONAL DETAILS
Name:
School / Department:
National Insurance Number:
PERIOD OF SICKNESS ABSENCE
Date absence began:
Last date of absence:
Date of return to work:
REASONS FOR ABSENCE
Please tick all that are applicable and provide brief description below
Anxiety / Depression/Other Mental Health
Condition
Asthma
Back Problems
Benign and Malignant Tumours / Cancers
Blood disorders (e.g. anaemia)
Burns/poisoning / frostbite / hypothermia
Chest & respiratory problems – excluding nose
& throat/asthma/cold/cough/flu
Cold/cough/influenza
Dental and oral problems
Ear / nose / throat (ENT)
Endocrine / glandular problems (e.g. Diabetes
/ thyroid / metabolic problems)
Eye problems
Gastrointestinal Problems
(e.g. abdominal pain / vomiting / diarrhoea)
Genitourinary & gynaecological disorders –
excluding pregnancy related disorders
Headache / migraine
Heart / cardiac / circulatory problems
Injury / Fracture
Nervous system diseases (e.g. Multiple
Sclerosis / Cerebral Palsy / Epilepsy)
Other Musculoskeletal Problems (not back)
Pregnancy related disorders
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July 2015
Skin disorders
Stress
Infectious disease – hand foot and mouth /
malaria / meningitis / measles / mumps /
shingles
Substance misuse – Including alcoholism &
drug abuse
Substance misuse – Including alcoholism &
drug abuse
Details of sickness absence:
..…………………………………………………………………………….…………………………....
……………………………………………………………………………………………………………
I declare that I have not worked during the above period of sickness and that the information
given is correct.
Signed: …………………………………………………..
Date: …………………………..
Please pass this form to your manager for discussion at a return to work meeting.
Manager: I confirm that I have met with the above named to discuss this period of sickness.
Signed: …………………………………………………..
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Date: …………………………..
July 2015