Report of absence due to sickness CHRIS/63
This form is to be used for reporting sickness absence to Personnel. It should be completed for all incidences of
sickness absence of four consecutive calendar days or more (including weekends and other non-working days).
Periods of less than four days in a week do not need to be reported unless contractual pay is immediately affected
(e.g. half pay or no pay is due). Please submit this form weekly for continuous absences and inform us immediately
the employee returns to work. Information on the University’s sickness policy is available on the Personnel Division
Section A – Personal Details
Enter the personal details
of the employee and tell
us what job they do. This
is necessary because it is
possible for an employee 3. Personal
to be absent from one job Reference Number
due to sickness but not
from another. 4. Job title
5. Faculty /
Section B – Sickness Details
Questions 7 and 8 should 6. Have you already submitted a CHRIS/63 for this sickness absence? (I.e. is this an
include weekends and ongoing illness?)
other non-working days.
Only complete questions
8 and 9 if the employee 7. Sickness start
has returned. Please date
submit a further form to
8. Last complete day
the payroll section as
soon as possible after
these dates are known. 9. Date returned to
In question 10, the
University is requesting 10. Sickness reason Tick
sickness absence reason one
in order to monitor trends Back, muscle or joint strain
and, in the case of a Blood disease
return to work after a Cancer
serious illness, to Chest/breathing difficulty
anticipate any reasonable Cold or Flu
adjustments that may be Dental problem
needed to the working Ear, nose or throat problem
environment. Eye problem
Heart or circulation problem
Stomach or gut problem
Other. Give details:
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Section C – Working pattern
It is very important that 11. Working pattern
we know what days of Every weekday Monday-Friday
the week the employee is Specified below
working in order that we
can calculate their sick
pay entitlement correctly. Mon Tue Wed Thu Fri Sat Sun
In question 12, tell us the
start date of this pattern If the working pattern is not straightforward, explain below.
(even if in the past).
12. Start date of this
Section D – Other circumstances
If your employee has 13. Is the employee in the latter stages of pregnancy?
been absent and has
Yes answer question 14) No (→ go to question 15)
been in receipt of
incapacity benefit and has
received a linking letter, 14. Expected date of
please enclose a copy childbirth
with this form.
15. If a new employee, has the employee received any of the following state benefits
within the last 57 days: sickness (if form SSP1(L) was issued by the previous
employer, please enclose it), incapacity, maternity, adoption or Benefit Agency award
16. Is this absence due to an accident or injury at work?
17. If yes, has an accident report form been completed and submitted?
18. Is this absence a result of an accident outside work for which a claim for damages
may be made against another party?
Yes No Unknown
In order to properly calculate an employee’s sick pay entitlement, we need to know their sickness history.
Please attach details of this person’s sickness absence in the last 365 days. You can attach a PD/LC leave
chart form, or a copy of your own local records.
Now send this form to the Payroll Section, Personnel Division, The Old Schools, Trinity Lane.
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