Sickness Self Certificate	CHRIS/62
All employees should use this form to report all sickness absences to their departmental administrator or head of institution. After seven calendar days’ absence, you need a medical certificate from a doctor. Information on the University’s Sickness Absence Policy is available on the Human Resources Division website. 
Part 1 – Sickness Details
To be completed by the employee
Section A – Staff Details
	1. Full name	

2. Faculty / Department	

3. Position Held	

	
Section B – Absence Details
We need to ask for the reason for absence because the University has a duty of care towards it employees. For example, if your work is likely to exacerbate your condition we need to consider whether any adjustments to your work are justified.

Questions 4 and 5 should include weekends and other non-working days. This is required to ensure the correct calculation of statutory sick pay.

If you do not work standard working hours “AM” should be used for absences during the first half of your working day and “PM” for the second half.		Tick if half day
  AM         PM
4. First day unfit for work	

	

	

	

	

5. Last day unfit for work	

	

	

	

	

6. Date returned to work	

	

	

	

	

7. Reason for absence	
Tick one	

Back, muscle or joint strain	

Blood disease	

Cancer	

Chest/breathing difficulty	

Cold or Flu	

Covid-19 (Coronavirus)	

Dental problem	

Ear, nose or throat problem	

Eye problem	

Gland/hormone problem	

Headache/migraine	

Heart or circulation problem	

Infection	

Injury	

Mental health/stress	

Nerve problem	

Pregnancy-related problem	

Skin problem	

Stomach or gut problem	

Swine Flu	

Other	

8. Give details of treatment received, together with details if you ticked “Other” above

	

9. If accident, give details

	

10. Is the condition new or recurrent?
New	
	
Recurrent	

	
Section C – Other information needed for payroll purposes
If you have been absent and in receipt of Employment and Support Allowance, please enclose any linking letter you may have received.

	11. If your employment has recently begun, tell us if you have received any of the following in the eight weeks leading up to your absence?
Statutory sick pay	

Statutory maternity pay	

Employment and Support Allowance	

Statutory adoption pay	

12. Are all of the following things true: (a) you are pregnant; (b) your absence is related to your pregnancy; (c) you are in the final four weeks before your expected date of childbirth?
Yes	
	
No	

	

I confirm that I was unfit for work due to sickness in the period stated above and that the information I have given is correct and complete.  I understand that this information will be used to record my absence and calculate my entitlement to pay.

Signed								Date						

Now hand this form to your head of institution or departmental administrator.

Part 2 – Confirmation of receipt
To be completed by the Head of institution or nominee
Section C – Comments
Enter any relevant comments in question 13.

If the employee has ticked any boxes in question 11, please pass a copy of this form to the Payroll Section, Greenwich House, Madingley Rise. If the employee has ticked “Yes” in question 12, then their maternity leave must now begin. Please inform your HR School Team
	13. Comments

	

Signed								Name						

Position								Date						

Telephone						
Please now enter this absence onto the CHRIS system and keep this form with the employee’s personal file.