Self-Certification Sickness Form
Certifies a short absence yourself, where no doctor’s note is required.
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| Employee | [name] |
| Employee ID | [id] |
| Department | [department] |
| First day of sickness | [date] |
| Last day of sickness | [date] |
| Returned to work on | [date] |
| Prevented from working | Yes, throughout |
Nature of the illness
[what was wrong — a general description is enough]
I certify that the information above is true and that I was unable to work for the period stated.
What is a Sickness Self-Certification?
A sickness self-certification is the form you complete yourself for a short illness, covering the days before a doctor's note becomes necessary. It converts an absence from unexplained to recorded. Without it, payroll has nothing to justify statutory or contractual sick pay, the days can be logged as unauthorised, and a run of unexplained absences builds a disciplinary record that is hard to unwind months later.
Employees use it on the first day back after a short illness — flu, a stomach bug, migraine, a bad back — where the employer's policy allows self-certification for absences under a set number of days. Line managers use it as the input to the return-to-work conversation. Payroll uses it as the trigger to release sick pay. It is also used by agency staff, apprentices and part-time workers, who are often unclear whether it applies to them; in most policies it does, because entitlement follows the contract, not the job title.
The number of days you can self-certify before a medical certificate is required is set by national rules and by your contract, and the two are not the same. In the UK, statutory sick pay rules set a self-certification window and a fit note after it — check the current figure on GOV.UK. In India, ESIC and the state shops and establishments rules differ by state. In the US there is no federal sick pay entitlement; the rules come from state or city paid-sick-leave laws and your employer's policy. Australia's Fair Work evidence rules differ again.
Self-certification is not a medical certificate and carries none of its weight. It records what you say happened; it does not prove it, and it does not stop an employer asking for a fit note if the absence runs longer or the pattern concerns them. It does not create sick pay where the contract gives none, and it does not authorise the absence retrospectively if your policy required you to phone in on day one. It is also not a fitness-to-work clearance — a manager can still refer you to occupational health.
What to put in a Sickness Self-Certification
These are the details this template asks for. Anything left blank is marked in red on the preview so you can see what is still missing.
| Field | What goes in it |
|---|---|
| Issuing organisation | For example: Maple Grove Homeowners Association |
| Organisation address | For example: 1420 Kinnear Road, Columbus, OH 43212 |
| Issued to (full name) | For example: James Whitfield |
| Employee code optional | For example: EMP-20418 |
| Department optional | For example: Operations |
| First day of sickness | Free text |
| Last day of sickness | Free text |
| Nature of the illness | For example: a stomach virus |
| Did it prevent you working? | Free text |
| Returned to work on | Free text |
| Signatory name optional | For example: K. Srinivasa Rao |
How to write a Sickness Self-Certification
State the exact dates you were absent
Give the first and last calendar day you were away, and whether you worked any part of either day. Write ‘Monday 3 to Wednesday 5 inclusive, three working days’ rather than ‘about three days last week’. Payroll counts waiting days and qualifying days from these dates, so an approximation forces someone to come back and ask, delaying the payment.
Describe the illness in plain terms
You are not writing a diagnosis. A short factual description is enough: ‘sickness and diarrhoea’, ‘migraine’, ‘lower back pain’. Avoid both extremes — ‘unwell’ tells the employer nothing and invites a follow-up, while a detailed account of symptoms and medication puts health data into a personnel file that does not need it. One line is the right length.
Record when and how you notified
Note the date and time you first told your employer, who you told, and by what channel — a call to your line manager at 08:10, a message on the team channel, an email to HR. This is the part most often left blank and the part most often disputed later. If you notified late, say so and give the reason rather than leaving the box empty.
Answer the work-related and accident questions
Most forms ask whether the illness was caused by an accident at work or by a third party. Answer honestly. A yes routes the absence into a separate accident report and, in some jurisdictions, an insurance or workers' compensation process with its own deadlines. Ticking no to avoid paperwork can close off a claim you were entitled to make.
Sign, date and hand it in promptly
Sign and date the declaration on your first day back, not at the end of the month. Many policies treat a late form as an unauthorised absence regardless of the illness. Keep a copy — a photograph of the signed sheet is enough — because if sick pay is queried six months on, the form is the only evidence that you certified the days at the time.
Common mistakes
- Writing ‘unwell’ as the reason, which tells the employer nothing and usually triggers a request for a fit note you did not need.
- Self-certifying more days than your policy allows, so the extra days fall outside sick pay and are recorded as unauthorised leave.
- Leaving the notification date and time blank, which makes it impossible to show later that you reported the absence on the first morning.
- Filing the form weeks after returning, by which point payroll has already run and the correction has to go through as an adjustment.
- Certifying a period that includes days you actually worked from home, which overstates the absence and reduces your remaining sick pay entitlement.
Frequently asked questions
How many days can I self-certify?
It depends on where you work and what your contract says. UK statutory sick pay rules set a self-certification window before a fit note is needed — check the current figure on GOV.UK. Elsewhere the limit comes from state law, an award, or company policy. Your staff handbook is the first place to look; it cannot give you less than the statutory minimum where one exists.
Do I have to say what illness I had?
You have to give a reason, but not a diagnosis. A short description — a chest infection, a migraine, a stomach upset — satisfies the form. Employers are handling health information, which in the UK and EU is special category data under data protection law, so they should collect only what they need. If you are asked for more detail than the form requires, ask why it is needed.
Can my employer refuse to accept a self-certification form?
An employer can question it, and can decline contractual sick pay if the policy was not followed — a late form, no phone call on day one, or a pattern of Friday and Monday absences. Refusing a statutory entitlement is a different matter and is governed by the sick pay rules where you work. If pay is withheld, ask for the reason in writing so you have something to take further.
Does a weekend or bank holiday count in the absence?
For the form, record the calendar dates you were unfit for work, including non-working days if the illness spanned them. Whether those days count for sick pay is a separate calculation done by payroll under the applicable rules, and it varies. Do not adjust the dates yourself to make the sums work — record what happened and let payroll apply the policy.
What if I was off sick for longer than the self-certification limit?
Self-certify the days inside the limit and get a medical certificate for the rest, dated to cover the remaining period. Ask the clinician to date it from the day after your self-certified days end so there is no gap. A gap between the two documents is the most common reason sick pay is queried, and closing it later means going back to the practice.
This page explains general practice and is not legal advice. Requirements differ between countries and, in some cases, between states — check what applies where the document will be used.