Self Certification Absence Report

In the event that an employee is unfit to attend work, they must telephone their line manager by 09:00 hrs. On their first day of absence, outlining the reason and indicating if possible when they would be expect to return to work.

Information

ParkingEye Ltd
Personal Details
Employee's Name:
Department:
Manager's Name:
Conducted on:
Location:

Absence Details

First date of absence
Final date of absence
Total number of days absent:
Please detail the reason for absence choosing from the list of absences:
- Allergies, Hay Fever
- Anaemia
- Anxiety, Depression, Nervous Illness
- Asthma
- Back, Neck and Spinal disorders
- Blood Pressure disorders
- Cancer, Chemotherapy
- Chest conditions
- Cough, Cold,Tonsillitis etc.
- Dental disorders
- Diabetes
- Disability- related conditions
- Ear conditions including Vertigo
- Epilepsy
- Exhaustion, Fatigue
- Eye conditions
- Face and Mouth disorders
- Gynaecological disorders
- Head Injury, Concussion
- Headache, Migraine
- Heart conditions
- Hernia
- Hospital Visit
- Infectious Diseases eg. Measles
- Influenza/Swine Flu
- Joint pain eg. Arthritis
- Kidney and Bladder disorders
- Lower limb injury
- Operation
- Post-operative recovery
- Pregnancy-related conditions
- Skin conditions
- Stomach disorders
- Stress-related illness
- Upper limb injury
- Wounds or Burns
Did you receive medical treatment during your absence?
If yes, please state where and when below
Location:
Please enter time and date:
Is your absence as a result of an occupation injury