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SSP - Employee Statement of Sickness
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This form can only be used for the 1st 7 calendar days of a sick absence (i.e. 10th - 16th). Kindly use the table below to correctly complete your self certification:
Covid-19 rules linked to self certs have now ended. All self certs have reverted to a maximum of seven calendar days.
If dates provided exceed this, we will only be able to process for the 1st seven days & you will need to supply medical certification from day 8+ - you
will not
be notified where you provide certification longer than allowed.
*
Employee Number - Numbers only NO LETTERS
Required
- Required.
*
Name
Required
- Required.
*
Date of Birth
Required
- Required.
*
National Insurance Number
*
Contact Telephone Number
Required
- Required.
*
Brief details of sickness
Required
- Required.
Covid-19 (Coronavirus) including Self-Isolation
Vaccination Reaction
Arthritis, joint pain, muscle strain, backache, sciatica, lumbago
Blood conditions
Bronchitis, chest infection, cough, cold, influenza, tonsillitis, asthma
Cancer
Chest pain, heart trouble, hypertension
Diabetes, thyroid, endocrine
Ear nose & throat, dental
Eye, ophthalmic
Gastro enteritis, upset stomach, diarrhoea, vomiting, food poisoning, irritable Bowel, stomach ulcer
Genito-urinary
Gynaecological, pregnancy related
Headache, migraine
Kidney infection, cystitis, Crohn’s disease
Neck, shoulder, upper back pain, hand or wrist pain
Skin, dermatological
Stress/anxiety/depression
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