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Valentine Health Partnership > About Us > Practice Policies > Website Policies > Online Forms > Staff Self Certification form

Staff Self Certification form

Staff Self Certification

First Name

Last Name

Department

Date illness began (including non-working days)

Dates of Absence

Date of first absence from work

Time:

Date returned to work:

Are your weekly hours variable?

How many hours per day are you scheduled to work?

Please advise how many hours you were scheduled to work ( as per rota) on each sick day. This information is required for Payroll purposes

Mon

Tue

Wed

Thu

Fri

Sat

Mon

Tue

Wed

Thu

Fri

Sat

Did you inform the Company on your first day of sickness/absence?

Notification Date

Notification Time

Method of Notification

Details of sickness or injury: (Please specify reason for absence, words such as ‘Ill’ or ‘sick’ are insufficient)

Do you believe that your factors at work caused or contributed to your illness/injury?

Please provide details ( to be forwarded to the Health & Safety lead)

Did you consult a medical practitioner?

Please provide details including date of visit, treatment received and any current medication.

I certify that I have been incapable of work because of my sickness/injury on the dates shown above and that this information is true and accurate.

I acknowledge that false information will result in disciplinary action.

I hereby give my employer permission to verify the above information.

Do you consent for this form to be shared with the Payroll department?

Yes

Signature

Clear

Date

If you are human, leave this field blank.

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Staff Self Certification form