Self Certification Sick Form v0.1 200921

Self Cert form Please complete this form on the first day of return to work and email (preferable), fax, email or post to the Sign Solutions’ office Self- Certification sickness form TO BE COMPLETED BY THE EMPLOYEE: Name: (Date) I certify that my first day of sickness (Date) wI caesr:tify that my last day of sickness was: (Date) I returned to work on: Total number of working days absence: Details of illness: Was a doctor consulted? YES / NO Name & address of doctor: Doctors/hospital certificate attached? YES / NO I declare that the information given in this declaration is complete and correct Signed: Dated: *Signature not required if form is emailed (your email will be kept and deemed as proof of signature) TO BE COMPLETED BY AGENCY MANAGER Details of periods of sickness in the past 12 months Inits Dates (from/to) PAID SIUCNKPAID SICKOMP LERAEVAESON FOR SICK/COMP Open Excel staff record, copy relevant info and then double click on grey box and past into the spreadsheet. Resize as required. Please also note whether time was paid or unpaid Employee entitlement as per length of service days Episodes Less paid sickness in past 12 months days Episodes Balance of remaining days/episodes days Episodes TO BE COMPLETED BY FINANCE MANAGER OR AGENCY MANAGER OR CEO I authorise (tick one): V0.1 20/09/21

Tick one and sign Full payment (OSP) in line with length of service served (see above) ….. days full pay (OSP) and ….. SSP only No payment of OSP Once authorised, please email form to Finance Dept (payroll)