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Self-Certification Form

This self-certification form is used to record sickness absence information for employees. It requires employees to provide their name, absence dates and reason. For absences over 7 days, a medical certificate is needed. Employees must notify their manager of any illness and submit this form on return. Managers must discuss absences with employees and ensure absences are recorded appropriately. The purpose is to monitor sickness trends while keeping individual records confidential in accordance with data protection laws.

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472 views

Self-Certification Form

This self-certification form is used to record sickness absence information for employees. It requires employees to provide their name, absence dates and reason. For absences over 7 days, a medical certificate is needed. Employees must notify their manager of any illness and submit this form on return. Managers must discuss absences with employees and ensure absences are recorded appropriately. The purpose is to monitor sickness trends while keeping individual records confidential in accordance with data protection laws.

Uploaded by

HRM Services
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Self-Certification Form

This form should be completed for all periods of sickness absence. If the absence is for less than 7 days the form can
be completed upon return to work. However, if the absence continues for longer, the form should be sent to the
employee to complete, or be completed by the line manager and confirmed by the employee at the earliest
opportunity.

a) To be completed by the employee: (Please refer to notes below when completing this form)

Employee Name: SAP Personnel Number:

Service: Post Title:

I certify that I was absent from work due to sickness during the period stated below:

Date sickness absence started*: Date sickness absence ended*:

Number of working days absent:


(For absence monitoring purposes)

▪ * Please note that all days should be counted, not just working days, in line with Statutory Sick Pay requirements.

▪ If the absence was for more than 7 days, please attach to this form a medical certificate from your GP.

My reason for absence was as follows: (please tick appropriate box)

Viral Infection
□ Stomach, Liver, Kidney &
Digestion (inc. diarrhoea, □
vomiting and stomach upset)

Eye, Ear, Nose and Mouth/


Dental □ Back Problems
□
Stress/depression/Mental
Health/Fatigue Syndrome (inc. □ Other Musculoskeletal
Disorders (inc. neck,legs,feet,
arms or hands; also joint problems
□
anxiety, nervous debility/disorder
& M.E.). Other Mental Health Reason such as arthritis)

Work Related Stress


□ Critical Illness (inc. cancer,
major organ transplant, stroke
etc)
□
Migraine/Headache
□ Surgery Related Absence
□
Cold/Flu (inc. coughs, throat
infections, etc) □ Accident at Work
□
Chest, Respiratory (for example
asthma, bronchitis, high fever). □ Accident outside work
□
Heart, Blood Pressure,
Circulation
□ Gynaecological / Menopausal
□
Substance Misuse
□ COVID-19
□
Other reasons for absence
(This code should only be used
if the reason for sickness absence
is not listed above)
□
Notification of Illness

If for any reason you are unable to come to work due to ill health, you must notify your line manager giving the
reason as quickly as possible on that day. Immediate notification is important and delay could jeopardise your pay
entitlement. If your absence continues after the third working day you must contact your line manager as to the
nature and possible duration of your illness. This form is to be completed on your first day of return to work.

A medical certificate must be obtained and sent immediately to your line manager if your sickness lasts more than 7
calendar days. For all such absences you will be required to complete this form in respect of the first 7 days either
during your absence (in which case the form will be sent to you) or on your return to work.

PURPOSE
The purpose of keeping sickness absence records is to monitor overall sickness absence trends across the authority
(without identifying individual cases) and to enable line managers to monitor individual absence levels/trends,
discussing with and supporting employees where issues are identified. In addition, the Council must meet statutory
obligations in relation to sick pay and statistical returns for example, Best Value Performance Indicators. All records
are kept confidentially and access to them restricted. From 1 April an employee will be able to view their individual
absence record through Employee Self Service on SAP or via their line manager.

DATA PROTECTION
The information given in this form will be processed for calculating sick pay entitlements and absence monitoring
purposes in accordance with the Data Protection Act and associated legislation.

NOTE
In accordance with the relevant conditions of service, the Council may, at its discretion, refer an employee to the
Occupational Health Physician or other medical practitioner as appropriate. Medical evidence relevant to periods of
absence may also be obtained from an employee’s doctor by a doctor nominated by the County Council with the
employee’s consent. Any referral will have regard to the provisions of the Access to Medical Reports Acts 1988. The
intention is to provide individuals with a measure of access to medical reports provided by their doctors. This is
achieved by giving individuals a right to see, comment on and consents to the provision of such reports.

If the County Council for any reason withholds Statutory Sick Pay, the employee will have the right to appeal through
the agreed procedure.

DECLARATION
I declare the reasons shown for my absence and the information given on this form is correct, to the best of my
knowledge. I understand that making a false statement may result in disciplinary action being taken and sick pay
being terminated.

Signature: Date:

Full Name: (please print)

b) To be completed by the line manager

I certify that I have:

● discussed this absence with the employee


● ensured that the necessary certifications are completed and retained by me
● ensured that the absence is recorded via MSS or ensured the Payroll Team has been notified using the
Notification of Absence form (only where the manager does not have access to MSS)

Signature of Line Manager: Date:

Full Name: (please print)


Updated Oct 2020

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