Employee Self-Service | Absence Record Form

Date of first day of absence*

Date of final day of absence*

Date of Return to Work*

Total Days Absent from Work*

Reason for Absence*

Was Medical Advice sought?*

No

Yes

If so, has their GP issued a Written Statement of Fitness for work?*

No

Yes

If so, does it suggest any adjustments to their role?*

No

Yes

If so, what are these?*

Is Absence due to an Injury / Accident at Work?*

No

Yes

If so, has an Accident Form been completed?*

No

Yes

I declare that I was absent between the dates stated above and that the reason given is correct.
I am aware that giving false or misleading information could lead to disciplinary action or the withdrawal of sick pay. *

Return to work form

To be completed by the employee at the start of his / her first day back at work.