This is to be completed in the event of an absence through sickness.

A Doctor's Certificate must be produced for an absence of more than five consecutive working days.

Name

First Name

Last Name

I CONFIRM THAT I WAS ABSENT FROM WORK FOR THE PERIOD: FIRST DAY ABSENT:

YYYY

DAY RETURNED TO WORK:

YYYY

THE REASON FOR MY ABSENCE FROM WORK WAS:

I DID/DID NOT ATTEND MY GP:

Yes

WHO DID YOU INFORM ON THE FIRST DAY OF MY ABSENCE:

DECLARATION. I DECLARE THAT THIS REPORT IS A TRUE STATEMENT.

I UNDERSTAND THAT IF I PROVIDE FALSE INFORMATION IN THIS REPORT IT WILL BE REGARDED AS SERIOUS MISCONDUCT, AND I WILL BE LIABLE TO DISMISSAL.

Yes

Employees Signature: