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Self Certification and Return to Work Form

Please complete both of the forms below.

Self Certification of Sickness
Please note that refusal to complete this form, or knowingly to provide false information, may result in disciplinary and/or legal action being taken, including the possibility of dismissal. Entitlement to sick pay depends on accurate completion.
Return to Work
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Number of Working Days and number of Occasions
Trigger points: • 4 or more periods of absence in a rolling 12 month period. • 10 days* absence over a 12 month period, either separate or continuous working days (*pro rata for part time staff - see Guidance Document). • Where there is a cause for concern regarding an employee’s health, even where there may be no absence. • There is a particular pattern of absence • A continuous period of 4 weeks absence.
• If approaching a trigger point, discuss the triggers within the sickness absence management policy and the implications of the employee’s absence levels, where appropriate, including a referral to a Stage One meeting. • Discuss a referral to Occupational Health where appropriate. • Share the Employee Assistance Programme details / Healthy Council intranet pages. • Share the Employee Health & Wellbeing policy where appropriate.