Weekly Sickness Absence Reports

Notes for guidance: 1. This form is necessary for implementing sick pay regulations and keeping of records by law. 2. The completed form must be sent to HR Operations on the Monday following the week covered by the return. A copy should also be sent to the Departmental Superintendent/Administrator and one retained within the department. 3. Please mark the days absent by using the letter X. 4. Please indicate whether the absence could be work related by referring to the certificate authorising the absence 5. If no persons are absent then a ‘NIL RETURN’ is required. 6. Personal Sickness Certificates or Doctors Certificates should be attached to the form. Please complete the following in block capitals.

WEEK ENDING SUNDAY ______DEPT ______SECTION ______

Name Mo Tu We Th Fr Sa Su Reason (see attached No. of Could it Cert

list) Working be work Attached?

Days related? Y/N

SIGNED ______PRINT NAME ______

CATEGORY EXAMPLES CATEGORY EXAMPLES Musculo-skeletal Sciatica Respiratory Colds, flu Back & Neck Pneumonia / bronchitis Asthma - work–related Asthma - other Lung infections TB

Operations Human Resources F: 01707 666402 SICKNESS ABSENCE CATEGORIES If you are uncertain what category to use please contact Human Resources.

Musculo-skeletal Arm, hand Skin Eczema Upper limb Shoulder Psoriasis Shingles Infections Allergy - work-related Allergy - other Musculo-skeletal Lower limb Genito Urinary Recurrent miscarriage other Head injuries Cystitis Other injuries Stones Road traffic accidents Pregnancy Multiple injuries Hysterectomy Abdominal strain D & C Arthritis Prostate conditions Inguinal Hernia Period pains Hiatus Hernia Irregular bleeding Women’s complaints Cardiovascular High blood pressure Nervous system Migraine Angina / Heart Attack Multiple sclerosis Stroke Epilepsy Deep vein thrombosis Vertigo (DVT) Cerebral Palsy Varicose veins Palpitations Heart operations Reynaud’s Disease Blood Disorders Gastro-intestinal Bowel disorders Misc symptoms Malaise / debility Liver / Gall bladder Headache Acid reflux Dizziness Diarrhoea / Vomiting Glandular Fever Haemorrhoids (piles) Post viral lethargy Appendicitis Ulcer Mental Ill Health Major psychiatric illness ENT & Eyes Allergy - work-related Stress / PTSD (Ear, Nose & Throat) Allergy – other Anxiety / Panic disorder Infections / sinusitis Depression Hayfever Eating Disorders Sleep Apnoea OCD Drug induced psychosis Cancer Unspecified cancers Other Childhood (infectious) Hodgkins Lymphoma diseases Leukemia Alcohol and drug addiction Dental Indecipherable conditions Endocrine Diabetes Hypo/hyperthyroid