Absence Related Forms

Please see below for a number of important absence support forms, toolkits and FAQ documents to support you!

Important Forms

• Return to Work Form
• Self Certifcation Form

  Self Certification - Form

  Please complete the form below in full. All information marked * is mandatory.

  This form is to be completed by trainees to cover:

  • Absences lasting 7 calendar days or less
  • The first 7 days of absence lasting 8 or more days (this form must be returned with your Certificate of Fitness)

  NB Failure to complete and submit this form to the designated person could result in the loss of sick pay and statutory sick pay, and may lead to disciplinary action.

  Trainee name: *

  Trainee GMC number: *

  Date: *

  Speciality: *

  Region: *

  Host organisation: *

  Trainee's email: *

  Assignment number: *

  Absence start date: *

  Was the absence a half day: * SelectYesNo

  Absence end date: *

  First working day of absence: *

  Last working day of absence: *

  Return to work date: *

  Absence Information

  Reason for absence: * SelectAnxiety/Stress/Depression/Other Psychiatric IllnessesAsthmaBack ProblemsBenign and Malignant Tumours/CancerBlood Disorder/Burns/Poisoning/Frostbite/ HypothermiaChest & RespiratoryCold/Cough/Flu/InfluenzaDental & Oral ProblemsEar/Nose/ThroatEndocrine/Glandular ProblemsEye ProblemsGastrointestinal ProblemsGenitourinary & Gynaecological DisordersHeadache/MigraineHeart/Cardiac/Circulatory ProblemsInfectious DiseasesInjury/FractureNervous System DisorderOther Muscoloskeletal ProblemsPregnancy Related DisorderSkin DisorderSubstance AbuseOther - Not Specified Above

  If other for the above please state further:

  Type of absence: * SelectWork InjuryWork Related SicknessPregnancy Related IssueOther SicknessAccident Outside of Work

  Did this accident cause you to consult a medical practitioner or attend hospital?: * SelectYesNoNA

  Was your injury due to an accident involving a third party, e.g. road traffic accident? (NB If the answer is ‘yes’ and damages are received from third party you will not be entitled to occupational sick pay and would be expected to return the net pay to the Trust): * SelectYesNoNA

  Trainee Declaration

  I confirm that the above information is accurate and that (Please select YES where appropriate)

  I confirm that during the period of being unfit for work I did not undertake any unpaid or paid work, study or training which was not approved in advance and in writing by my line manager: SelectYes

  I confirm that during the period of being unfit for work I undertook unpaid or paid work, study or training which was not approved in advance and in writing by my line manager: SelectYes

  Trainee signature: *

  Date: *

  Send

Important Toolkits

• Stage 1 Absence Toolkit

  Please click here for the stage 1 absence toolkit.

• Stage 2 Absence Toolkit

  Please click here for the stage 2 absence toolkit.

• Level 1 Absence Toolkit

  Please click here for the level 1 absence toolkit.

• Level 2 Absence Toolkit

  Please click here for the level 2 absence toolkit.

Stages and Levels FAQs

• Host FAQ Document

  Please click here for a stages and levels host specific FAQ sheet.

• Colleague-in-Training FAQ Document

  Please click here for a stages and levels colleague-in-training specific FAQ sheet.

ESR Sickness Codes

• ESR Sickness Codes

  Please click here to check out the different type of Electronic Staff Record (ESR) sickness codes.