Sick note request form

You must self certify for the first 7 days of illness.

Your sick note will be ready to collect within 72 hrs from Reception.

Your Details

Full Name *

Date of Birth *

Phone Number

What is your job title? *

Please outline the duties of your job role

Information about your illness/injury

What is the reason for your inability to work? (please give specific details of your injury/illness) *

How has your illness/injury affected your ability to do your job? *

What date would you like the sick line to start? (It is not possible to forward date them, but we can backdate them) *

Please indicate the expected length of time off required (ie: 1 week, 1 month) *

What type of sick line do you require? *

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Page last reviewed: 18 January 2024
Page created: 03 February 2023

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