Sick Leave Self-Certification Form

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]