Staff Sickness Report Form

Please complete this form in full, including uploading electronic copies (photograph/scan) of any relevant documentation such as sick/fit note.

Staff Details:
Your name: Your name: First Last
Sickness Start Date: Sickness Start Date: / DD / MM YYYY
Sickness End Date Sickness End Date / DD / MM YYYY
Number of Hours Off Work:
Notification:
Who did you notify? Who did you notify? First Last
Who is the responsible Case Manager?
Date of notification: Date of notification: / DD / MM YYYY
Time of notification: Time of notification: : HH MM AM/PM
Do you have a Statement of Fitness for Work (fit note) from your Doctor?

Do you have a Statement of Fitness for Work (fit note) from your Doctor? Yes No
Upload a scanned/photo copy of your fit note
Further details:
Reason for your illness/sick leave:
Declaration:

By submitting this form, you confirm that the information provided in this form is true and correct, to the best of your knowledge. You understand that any false or misleading information provided may led to disciplinary proceedings, or dismissal. You must seek to correct any inaccurate information at your earliest opportunity.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature, and I agree to the above statement. Clear

Full Name

I understand this is a legal representation of my signature, and I agree to the above statement.
Today's Date: Today's Date: / DD / MM YYYY