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Get Self Cert Sick Note

CONFIDENTIAL Sickness Self-Certification Form EMPLOYEE DETAILS Full Name Department Payroll No. Job Title from your payslip DATES OF SICKNESS First full day of sickness Last full day of sickness Date returned to work Please state briefly why you were off work sick Was this as a result of an accident/injury at work Yes No Declaration to be completed by the member of staff reporting the absence I confirm that I was unfit for work due to sickness in the period stated above and that the information I have given is correct and complete. I understand that making a false statement may result in disciplinary action being taken and sick pay being terminated* I understand that this information will be used to record my absence and calculate my entitlement to pay. Date 19/10/11 FOR DEPARTMENTAL USE ONLY Comments Return to work interview held Opendoor code Date entered on system REASONS FOR ABSENCE CODE LIST ALL Allergy DENT Dental EYES Eyes HBP Heart Blood Pressure HMH Headache/Migraine/Head pain INF Infections colds/flu/dv/etc MAT Maternity related MHNS Mental health not stress MSB Musculoskeletal back NS Not specified OTH Other SKIN Skin SURG Surgery/convalescence. I understand that making a false statement may result in disciplinary action being taken and sick pay being terminated* I understand that this information will be used to record my absence and calculate my entitlement to pay. Date 19/10/11 FOR DEPARTMENTAL USE ONLY Comments Return to work interview held Opendoor code Date entered on system REASONS FOR ABSENCE CODE LIST ALL Allergy DENT Dental EYES Eyes HBP Heart Blood Pressure HMH Headache/Migraine/Head pain INF Infections colds/flu/dv/etc MAT Maternity related MHNS Mental health not stress MSB Musculoskeletal back NS Not specified OTH Other SKIN Skin SURG Surgery/convalescence.

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