ࡱ> BDA5 ~bjbjl2l2 :4XhXh*P  864j<A$#######$&y)#"#W#e e e 8#e #e e " #y"#$0A$#** # #* #e ##A$* X `: Strictly Confidential 91Ƭ Employee Self-Certification Form To be completed by all members of staff absent for a half day or more and returned to the colleague in the department/section responsible for maintaining sickness records. If anyone would like this form in a different format, they should contact Human Resources. 1. Confidentiality Sickness absence information is held electronically and will be processed in accordance with the Data Protection Act 2018 and the General Data Protection Regulations. The data will be used for statistical analysis in an anonymous form and made available to your Head of School/Department to help meet the Universitys obligation to ensure the health, safety and welfare at work of all colleagues. 2. Last Name ....................................... First names ................................................. Section/Department ...........................................................Staff Payroll No ................ 3. Length of Absence: First day of Sickness ........................day .......................... date ........................time Last day of Sickness .......................day ......................... ..date .....................time Total number of working days absent .................................... 4. Reasons for Absence (please select from the list overleaf with any appropriate additional detail) ................................................................................................................................................ ................................................................................................................................................ Did you receive medical treatment during your absence? YES/NO If so, please state where and when ......................................................... ................................................................................................. ................................................................................................................................................ Do you believe that your illness is as a result of an occupational injury/disease? YES/NO Declaration I declare that I have not worked during the period of sickness and that the above statement is true and accurate to the best of my knowledge. I understand that to give false or misleading information can result in disciplinary proceedings which may lead to dismissal, and that a false declaration can be an offence under statute and common law. Employee's Signature .................................................. Date .................................... Supervisors/Line Manager's Signature ...................................................................................... Date ............................................... Strictly Confidential 91Ƭ Employee Self-Certification Form Reasons for Absence Asthma and other chest/respiratory problems incl pneumonia, bronchitis, pleurisy Cancers and tumours (Benign and malignant tumours, cancers) Cold, cough, flu influenza/ Covid-19 Diabetes and other endocrine/glandular problems (e.g. diabetes, thyroid, metabolic problems) Eye, ear, nose, throat and dental problems Genitourinary and gynaecological disorders, incl menopause or perimenopause Headache, migraine and neurological/nervous system Heart, circulatory and blood disorders Operation/recovery/medical appointment Injury, burns and poisoning Mental health incl exhaustion, fatigue, nervous debility, alcohol/drug abuse Musculoskeletal incl back/neck problems, carpal tunnel, tendonitis Other infectious diseases (e.g. shingles) Pregnancy-related disorders Skin disorders Stomach/ digestive/ gastrointestinal problems (e.g. abdominal pain, gastroenteritis, vomiting, diarrhoea) exclude dental and oral problems Symptoms relating to the diagnosis of long Covid Other known causes not covered by the UCEA categories Unknown causes/not specified Hospital Visit Where none of the above reasons is appropriate, use Other and give details. A reason should be given in all but exceptional circumstances which should be discussed with Human Resources.     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