Temporary Workers' Sickness Self Certificate	CHRIS/73
Temporary workers should use this form to report all sickness absences e. After seven calendar days’ absence, you need a medical certificate from a doctor. 

Part 1 – Sickness Details
To be completed by the worker
Section A – Worker Details
	1. Surname	

2. Forenames	

3. Assignment details	

	
Section B – Absence Details
We need to ask for the reason for absence because the University has a duty of care towards its workers. 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.	4. First full day unfit for work	

	

	

5. Last full 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
Only complete question 13 if you have ticked “Benefits agency award” in question 11.

If you have been absent and in receipt of incapacity benefit, please enclose any linking letter you may have received.	11. If your assignment 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	

Incapacity benefit	

Statutory adoption pay	

Benefits agency award	

12. Details of benefits agency award

	

13. Are all of the following things true: (a) you are a pregnant woman; (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 statutory sick pay.

Signed								Date						

Now send this form to the 
For TES workers - Temporary Employment Service at Greenwich House, Madingley Road, Cambridge CB3 0TX or email a copy to temps@admin.cam.ac.uk.
For Casual Workers (engaged via CCWS) – please email a copy of this form to your line manager (for the assignment you are working on at the time of to this absence).

Part 2 – Confirmation of receipt
To be completed by the TES Team Leader or nominee
Section C – Comments
Enter any relevant comments in question 14. 	14. Comments

	

Signed								Name						

Position								Date						

Telephone						

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