Self Certification form

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1. Statutory Sick Pay (SSP): Employee's statement of sickness
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This form is designed to be filled in on screen. You must answer all the questions except those marked 'optional'. You can’t save the form but once you’ve completed it you’ll be able to print a copy and post it. Statutory Sick Pay (SSP) is money paid by employers to their employees who satisfy the conditions for payments when they are ill and unable to work. Please fill in this form on the first day of your sickness.
 

1. Your statement *

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2. Please give brief details about your sickness *

 

3. What date did your sickness begin?
The date you put in this box may be a day you don't normally work. If you're sick for more than 7 days, your employer may ask you for a medical statement of fitness for work 'fit note' from your doctor. *

   DD/MM/YYYY 
 
 

4. What date did you last work before your sickness began? *

   DD/MM/YYYY 
 
 

5. What time did you finish work on that date? (Enter time in 24 hours) *

 HHMM
 

6. Was your sickness caused by an accident at work or an industrial disease? *

 

7. Declaration
I confirm that the information I have given is correct and that any false information may be investigated *

 

8. Please supply contact details should we need to contact you. *

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