IN CONFIDENCE
PERSONAL SICKNESS CERTIFICATE
This form should be completed and sent to the Payroll Office on your return to work after a period of absence of 4-7
days. Periods of sickness of more than 7 calendar days should be certified by a doctor.
1.
2.
SURNAME
________________________________________________________
FIRST NAME
________________________________________________________
NATIONAL INSURANCE NUMBER
___________________________________________
DATE OF BIRTH
___________________________________________
ABOUT YOUR SICKNESS (please give brief details)
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
3.
DATE OF FIRST DAY OF SICKNESS (including Saturday, Sunday, Bank holiday etc) __/__/____
DATE OF LAST DAY OF SICKNESS (including Saturday, Sunday, Bank holiday etc) __/__/____
4.
PART-TIME STAFF ONLY
I would have expected to have been at work on the following dates (included above) had I not been ill.
…………………………………………………………………………………………………………………….
5.
DECLARATION
I declare that I have not worked during the period of sickness stated above and that the information
given is correct.
2014
Employee’s signature
………………………………………………………
Date
………………………………………………………