SELF-CERTIFICATION OF ABSENCE FORM
TO BE COMPLETED FOR ABSENCES OF UP TO SEVEN CONSECUTIVE DAYS UPON RETURN TO WORK
If you like to cliam SSP, please also attach fit note from medical professional.
Please complete all reuired area.
We will send the document for your signature after your submission and once it has been reviewed by your line manager.
EmployeeID
Employee name
Employee section —Please choose an option—LogisticCakeBreadFront EAFront CGFront MBHQ
PERIOD OF ABSENCE
Record ALL days of sickness including weekends or non-working days.
First day sickness:
Last day sickness:
Total days absent:
Do you like to claim SSP? (Please upload medical certificate): —Please choose an option—YesNo
Do you like to use available paid holiday: —Please choose an option—YesNo
How many paid holidays do you like to use?: —Please choose an option—All available days012345678910111213141516171819202122232425262728
Give brief details of the reason for absence which prevented you from attending work. (If off sick, words like ILL or UNWELL are not enough – please be specific.)
Did you visit your doctor? —Please choose an option—YesNo
Date of visit if visited:
Did you obtain a doctor’s certificate —Please choose an option—YesNo
Doctor/GP's name (Please fill in your GP name even if you have not visited this time):
Doctor/GP's address (Please fill in your GP name even if you have not visited this time:
I declare this information is complete and accurate and that I am now fit to return to work.
Form Submit Date: (date this form submitted)
Any false declaration on this form will be regarded as an act of misconduct and managed in line with the Disciplinary policy.
Please upload if you have any medial certificate or other document you like to send us.
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