Absence Form

Please fill out this form for all sickness absence of five calendar days or fewer and any other absence.

For periods of sickness lasting more than five calendar days, please provide a ‘Statement of Fitness for work’ (Fit Note) which has been signed by a doctor or your GP.

This form must be completed on the day you return to work.

Line managers to initial and send to HR.

Name*
First Last
Email*
Please state the reason for your absence. E.g. Sickness, Bereavement, Jury Service*
First day of absence*
Date returned to work*
Number of days away from work*
Number of hours missed from work in total*
Was your sickness caused by an accident at work?*
If so, please provide brief details and date of accident, inform the designated person and ensure the accident record book has been updated to include details of this accident.
If you have been unwell, are you now fit to work?
Please list any adjustments that need to be made by us to enable you to return.
Signature*
Date*
Date Format: DD slash MM slash YYYY
Name of Line Manager*