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Employee Absence Certificate by hallatt

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Blank Employee Absence certificate for use by a HR department.

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									ABSENCE CERTIFICATE AND STATUTORY SICK PAY CLAIM
To cover all absences other than holidays

You must complete this form on return from any absence lasting one day or more for reasons other than holidays, and return it to your departmental manager or director, for counter-signature. Christian name ....................................................... Surname............................................................. Dept .................................................................... Duration of absence Please indicate day and date sickness or other absence commenced including any day at weekend or on holiday*
Please circle appropriate day

First day of sickness/absence Date ....................... First day unable to attend office Date ....................... Last day of sickness/absence Date ....................... Returned to office on Date .......................

SAT

SUN

MON TUE WED THU MON TUE WED THU

WED THU FRI WED THU FRI

FRI

MON TUE SAT SUN

FRI

MON TUE

Number of working days absent ..................................... Total number of days absent ...................................... Please state reason for absence ......................................................................................................................

If you have been absent for 7 or more consecutive days including those at a weekend you must provide a medical certificate *delete whichever is appropriate a Did you seek medical advice *yes/no ........................If yes, from ..............................……………………………………………………… b *A medical certificate was obtained and a copy is attached *copies have been sent to the company The name, address and telephone number of my doctor is as follows Name ................................................................................... Tel no. .................................................................. Address ...................................................................................................................... ......................................……………………………………………………………………………………………. (I understand that no approach will be made to my doctor without my prior agreement.) I hereby certify that I was absent on the date(s) shown above for the reason(s) stated. I declare that the above statement is accurate to the best of my knowledge and understand that to give misleading information can result in disciplinary proceedings, which may lead to dismissal. Signed .........................................................................

Date .................................................................. Countersigned Director/manager .........................................................................

Date .................................................................. When complete please give the top copy (together with any medical certificates) to XXX who is the person responsible for compiling the monthly absence summary of XXX Ltd. The other copy should be retained for your files.


								
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