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Leave & Time
Sick Leave Self-Certification Form
A self-certification form for short-term sick leave absences without a doctor's note, capturing absence dates, reason, and manager acknowledgment.
SICK LEAVE SELF-CERTIFICATION FORM
Complete this form for absences of [Number] consecutive days or fewer. Longer absences require a medical certificate.
EMPLOYEE INFORMATION
Name: [Full Name] | ID: [Number]
Department: [Department] | Title: [Title]
ABSENCE DETAILS
First Date of Absence: [Date]
Last Date of Absence: [Date]
Date Returned: [Date]
Total Days: [Number]
REASON
Nature of illness/injury: [Brief description]
Visited a doctor?: ☐ Yes ☐ No
If yes, doctor name and date: [Name], [Date]
Taking medication?: ☐ Yes ☐ No
DECLARATION
I confirm I was genuinely unable to attend work due to illness. I understand false information may result in disciplinary action. Sick leave will be deducted from my balance. If insufficient, the absence may be taken from annual leave or unpaid leave.
Signature: _______________________ Date: _______________________
MANAGER USE
Leave applied: ☐ Sick ☐ Annual (insufficient sick) ☐ Unpaid
Days deducted: [Days] | Notes: [Notes]
Manager Signature: _______________________ Date: _______________________
HR USE: Recorded in HRIS: ☐ Yes — by [Name] on [Date]