(Please complete in BLOCK CAPITALS) This form has been authorised by NAME: ........................................………………….…….. EXT: .....................…... CAMPUS: ...............…. DATE: ..........................
DEPT: ………......................................………………………………………………………..... SIGNATURE: ..........................................................……………………….......…………......... DETAILS OF ABSENT EMPLOYEE Surname: ................................…….. Forename(s): ….........................…… Title: ..………. Job Title: ............................................................……………
Full Time / Part Time YES/NO
Date of Birth: ………….. Term-Time Only:
NOTES ON THE COMPLETION OF THIS FORM : Staff who work a fixed, full or part time pattern: The manager should complete a form from the first day of absence. If the employee does not return on day 3 copies of this form should be sent to Payroll and Human Resources. A second form should be completed when the employee returns to work. Staff who work a variable, irregular pattern of days (eg not Monday to Friday): The manager should complete a form from the first day of absence. If the employee does not return to work in that week the form should be sent to Payroll and Human Resources. A new form should be completed for each week the employee continues to be absent.
First Date Unfit for Work Was the first day of absence for part of a day? EMPLOYEE’S WORKING PATTERN
Last Date Unfit for Work YES / NO
Date Returned to Work
Please specify number of working hours for each day the employee should have worked for this week. NB Full day is 7.4 hrs
MON TUES WED THUR FRI SAT SUN
hrs
hrs
hrs
hrs
hrs
hrs
hrs From: ……………. To: …………...
Doctor’s Certificate attached: YES / NO If YES – Dates Certificate covers REASON FOR ABSENCE (please tick and complete appropriate boxes) Sickness:
Reason: (Please select ONLY from list on reverse of form)
Accident:
If YES was it (Please delete as appropriate, definitions on reverse of
form)
At Work / Outside Work
Compassionate Leave: If YES was it (Please delete as appropriate)
Sickness / Death
Please state relationship to employee: ………………………………………………………………. Family Leave – UNPAID – (Dept to complete/payroll to action re payment) Time off for Dependants
Maternity: Paternity: Adoption:
Parental Leave
WHERE TO SEND EACH COPY OF THIS FORM : After completion you should retain the Yellow copy, send the Blue copy to Human Resources and the White copy to the Payroll Section.
PAYROLL USE ONLY MTH/WK SSP DUE/PAID
MTH/WK
SSP DUE/PAID
LAST DAY FULL PAY LAST DAY HALF PAY LAST DAY OF SSP PAY REFERENCE:
TRENT COMPLETED
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Reason for Sickness
ALLE ARTH BACK BROK BURN CANC DENT DERM DRUG EARN EATI ENDO EPIL EYEC GAST GYNA HEAD HEAR HOSP IMMU INFL INJU MALE NEUR OTHE PREG RESP
Allergy (including Hayfever) Arthritis Back/neck/limb and other musculo/skeletal conditions Broken bone/fracture Burns Cancer Dental Treatment Dermatological Drug dependency Ear, nose, throat & mouth Eating disorders Endocrine/metabolic conditions Epilepsy Eye condition Gastro-intestinal problems (Chronic conditions) Gynaecological Headache/Migraine Heart & circulatory problems Hospital treatment Immunological problems Influenza, colds etc Injury (other) Male Reproductive Neurological Other/Ill Defined Conditions Pregnancy Related Respiratory illness
SICK
Sickness, diarrhoea & food poisoning (short term) STRE Stress, Depression & Anxiety UROL Urological VIRU Virus/infection XANT XND Anthrax XCHI XND Chickenpox XCHO XND Cholera XDIP XND Diptheria XHAE XND Haemophilus Influenza Type B(Hib) (Meningitis notifiable) XHEP XND Hepatitis A XHEB XND Hepatitis B XMEA XND Measles XMEN XND Meningococcal meningitis XMUM XND Mumps XPER XND Pertussis XPNE XND Pneumococcal disease (Pneumonia, Bacteraemia and Meningitis) XPOL XND Poliomyelitis XRAB XND Rabies XRUB XND Rubella XSMA XND Smallpox and vaccinia XTET XND Tetanus XTIC XND Tick borne encephalitis XTUB XND Tuberculosis XTYP XND Typhoid XYEL XND Yellow Fever
Reasons Prefixed with XND : Reasons prefixed by XND indicate they are Notifiable Diseases. When a reason prefixed by XND is selected this will prompt action in Human Resources.
Accident at Work : This is defined as an accident that takes place when an employee is engaged on authorised legitimate University business. Please ensure an Accident Report form is also completed.
Accident outside of Work : When an employee suffers an accident outside of work (eg road accident or sports injury), and which does not fall within the definition of an Accident at Work.
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