EMPLOYEE SELF CERTIFICATION FORM
1. This form should be completed by you and given to your Supervisor/Line Manager
personally on your first day back at work after any sickness absence covering up to
seven calendar days or for the first seven calendar days of any longer absence
(even where a doctor's medical certificate has been provided). The information given
is treated as confidential
2. SURNAME: .................................................................................................................
FORENAMES: ............................................................................................................
ADDRESS: ..................................................................................................................
. ....................................................................................................................................
SCHOOL: ....................................................................................................................
3. I certify that I was unable to attend work due to illness on (please state dates):
. ....................................................................................................................................
4. The nature of my illness was:
(please select only one box – more detailed information available overleaf)
(
(
(
(
(
(
(
) Mouth, teeth, ears or eyes
) Glandular
) Stomach and digestive system
) Musculoskeletal system
) Skin-related
) Infectious disease
) Confidential *
(
(
(
(
(
(
(
) Respiratory system
) Cardiovascular system
) Reproductive system
) Urinary system
) Nervous system
) Mental health
) Swine Flu (suspected/confirmed)
* If you do not feel able to give details of your illness to your Supervisor/Line Manager
please select “confidential" in the above space and communicate the reasons in writing
to the Council's Occupational Health Unit (OHU) in a sealed envelope to accompany
this form.
5. I hereby declare that to the best of my knowledge the above information is true. I
realise that knowingly making a false statement would be fraudulent and will render
me liable to appropriate disciplinary action.
6. Signed: ……………………………………….........................Dated: .............................
7. Counter-signed (Supervisor/Line Manager): ...............................................................
8. To be completed by Occupational Health Unit (OHU) in cases where 'confidential'
has been inserted in Section 4.
I confirm that .....................………….. (name) has given me details of his/her illness.
Signed: ..........................………………………….………… Dated: ...................................
REASONS FOR SICKNESS ABSENCE (examples)
MOUTH, TEETH, EARS OR EYES
STOMACH DIGESTIVE SYSTEM
URINARY SYSTEM
Dental problems
Ulcerative Colitis, Crohn’s Disease
Cystitis
Earache / ear infection
Sickness/diarrhoea/nausea (including food poison)
Kidney problem (stone or infection)
Eye, infection e.g. conjunctivitis
Ulcer
Cancer / Other urinary tract
Dizziness, vertigo, Meniere’s disease
Irritable Bowel Syndrome
Cancer
Gall Bladder/Stones
SKIN RELATED
Other aural ocular dental
Appendectomy
Skin Rash
Cancer
Burn / scald
Other gastrointestinal
Dermatitis / Eczema
RESPIRATORY SYSTEM
Hayfever
Skin infection e.g. scabies
Asthma
REPRODUCTIVE SYSTEM
Wound / cut
Chest infection, e.g. bronchitis
Hysterectomy
Skin cancer / other dermatological
Cold / Influenza / Flu
Menopausal symptoms
Sinusitis
Period pains / Heavy periods
NERVOUS SYSTEM
Sore throat
Pregnancy related
Epilepsy
Cancer
Premenstrual Tension / Syndrome
Headache / migraine
Other respiratory system
Vasectomy
Multiple sclerosis
Cancer (e.g. breast, prostrate)
Cancer
Other reproductive
Other nervous system
Thyroid
MUSCULOSKELETAL SYSTEM
INFECTIOUS DISEASE
Cancer
Neck/back problems
Shingles, chicken pox
Other respiratory system
Fracture / Break / Crack
Tuberculosis
GLANDULAR
Diabetes
Rheumatism / arthritis
Hepatitis
CARDIOVASCULAR SYSTEM
RSI / Work-related upper limb disorder
Other infectious diseases
Heart disease
Strain / sprain (tennis elbow)
Angina
Shoulder problem
MENTAL HEALTH
Phlebitis / thrombosis
Cancer (bones / muscles)
Anxiety / depression
High blood pressure (hypertension)
Other musculoskeletal
Stress
Other cardiovascular
Other mental health
SWINE FLU
Suspected/Confirmed