Self-certification of Absence Form

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When you come back to work after time off sick, please make sure that you complete this self-certification of absence form.

If you have been off for more than 7 calendar days you will also need to bring a doctor’s note, if you haven’t already sent one in. You’ll need to have either a doctor’s note or a self-certification form to cover the whole period of your absence.

Please read the procedures set out in our Sickness Absence Policy before completing and sending this form.

The Bristol Bike Project treats personal data collected during the sickness procedure in accordance with the organisation's data protection policy.

Name *

Date you were first unfit for work *

YYYY

Date you were first off sick from work

YYYY

Date you were fit for work again (could be a weekend) *

YYYY

Date you returned to work *

YYYY

Days off sick *

This refers to the number of days you were on the rota to do which you missed.

Reason you were off sick *

Did you consult a medical professional? *

Yes

Did you see a doctor? *

Yes

Did you visit a hospital or clinic? *

Yes

Your signature *

Adding you name electronically will count as a signature

Today's date *

YYYY

Notes (anything else you'd like to add)

Submit

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