PRIVATE & CONFIDENTIAL - Self-Certification Absence Form

This form should be completed on your return to work following any period of sickness or absence of 7 calendar days or less and sent to your Line Manager.

If you are returning to work after a sickness of more than 7 days you MUST provide a Fit Note, available from your your GP or healthcare provider.

A copy of the completed form will be retained in line with Royal Docks Waterways' Data Protection Policy

1Absence Details > 2Line Manager Signature
SELF-CERTIFICATION ABSENCE FORM - Employee Name SELF-CERTIFICATION ABSENCE FORM - Employee Name First Last
Department
DATE/TIME OF ABSENCE OR SICKNESS (Non-working days i.e. weekends must be included) First Date of Absence or Sickness DATE/TIME OF ABSENCE OR SICKNESS
(Non-working days i.e. weekends must be included)

First Date of Absence or Sickness / DD / MM YYYY
Last Date of Absence or Sickness Last Date of Absence or Sickness / DD / MM YYYY
Return to work date Return to work date / DD / MM YYYY
Time of return to work Time of return to work : HH MM
Total Number of days absent

If the total number of days absent are greater than 7 you must provide a Fit Note.
Date the company was informed of your Absence or Sickness Date the company was informed of your Absence or Sickness / DD / MM YYYY
Time the company was informed of your Absence or Sickness Time the company was informed of your Absence or Sickness : HH MM
Who did you speak to?
REASON FOR ABSENCE OR SICKNESS

What was the reason for your absence or sickness?
Was your absence due to a work-related injury/condition?

Was your absence due to a work-related injury/condition? YES NO
If YES, has an accident report form been completed?

If YES, has an accident report form been completed? YES NO
If an accident report has not been completed, please explain why?
Is this absence related to a previous absence?

Is this absence related to a previous absence? YES NO
Did you consult a medical practitioner?

Did you consult a medical practitioner? YES NO
If YES, please give details of doctor's name, address, date of visit and any treatment received
DECLARATION
I certify that, on the dates shown, I have been incapable of work because of my:

DECLARATION I certify that, on the dates shown, I have been incapable of work because of my: Absence Sickness Injury
I acknowledge that false information could result in disciplinary action.

I acknowledge that false information could result in disciplinary action. YES
I hereby give my employer permission to verify the above information.

I hereby give my employer permission to verify the above information. YES
Draw or type your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Please save your progress and insert the email address of your line manager: Scott@royaldockswaterways.com Will@royaldockswaterways.com Sallu@royaldockswaterways.com
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