healey by chenmeixiu

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									SELF CERTIFICATION
FORM

This form must be completed by staff returning to work after a period of absence not covered by a
doctor’s statement of:
(a)   one to seven days
      Note: Self-Certification should cover the complete period of incapacity to work (see note 1 below)
(b)   the first seven calendar days of any longer absence which is not covered by a medical certificate

FULL NAME (BLOCK CAPITALS):                                            ..................................................................................................

Employee Number (if known):                                            ..................................................................................................

Job Title:                                                             ..................................................................................................

Faculty/Department:                                                    ..................................................................................................

I hereby certify that I was incapable of work from: ................................. to: ................................. (dates inclusive
                                                                                                                                                        See note 1 below)
Actual date I returned to work:                                        ..................................

The reason for my absence was: (Please tick appropriate box)

(a)      Illness                                                                                              □
(b)      Accident at work/industrial disease                                                                  □
         Have you completed a yellow Accident Report Form?                                                    □Yes                      □No
(c)      Other accident/injury                                                                                □
Describe actual symptoms/diagnosis of illness/nature of accident (see note 2 below): (please continue overleaf if necessary)




I certify that the above information is correct and claim any pay to which I may be entitled. I understand that any
deliberate false information given by me may render me liable to disciplinary action under the University’s Disciplinary
Procedure. Should my accident injury be subject to recoverable compensation from a third party I understand that I
will be required to contact Human Resources to discuss repayment of any sick pay, should compensation be awarded.

SIGNED: ...................................................................................       DATE: ............................................

TO BE COMPLETED BY LINE MANAGER
I confirm that the above information provided by the employee is to the best of my knowledge correct.

SIGNED: ...................................................................................       DATE: ............................................

DESIGNATION: .......................................................................................................................................

When completed this form must be sent to Human Resources, together with any medical certificates
where due.




NOTES FOR GUIDANCE
1 All days, including Saturdays, Sundays Public/College Holidays, days not required or rostered to work, must be included for the purposes
   of calculating statutory sick pay
2 In circumstances where you wish (because of the nature of the illness) to keep it confidential, you should complete this form as far as
    possible but must inform the Head of Human Resourcest, in writing, of the reason for the absence.

								
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