SELF CERTIFICATION FORM (SCF1A) - Home - Keele University



2747645444500Appendix B-252730223520SELF CERTIFICATION FORM (SCF1A)00SELF CERTIFICATION FORM (SCF1A)PERSONAL DETAILSName:School / Department:National Insurance Number:PERIOD OF SICKNESS ABSENCEDate absence began:Last date of absence: Date of return to work:REASONS FOR ABSENCEPlease tick all that are applicable and provide brief description belowAnxiety / Depression/Other Mental Health ConditionAsthmaBack ProblemsBenign and Malignant Tumours / CancersBlood disorders (e.g. anaemia)Burns/poisoning / frostbite / hypothermiaChest & respiratory problems – excluding nose & throat/asthma/cold/cough/fluCold/cough/influenzaDental and oral problemsEar / nose / throat (ENT)Endocrine / glandular problems (e.g. Diabetes / thyroid / metabolic problems)Eye problemsGastrointestinal Problems (e.g. abdominal pain / vomiting / diarrhoea)Genitourinary & gynaecological disorders – excluding pregnancy related disordersHeadache / migraineHeart / cardiac / circulatory problemsInjury / FractureNervous system diseases (e.g. Multiple Sclerosis / Cerebral Palsy / Epilepsy)Other Musculoskeletal Problems (not back)Pregnancy related disordersSkin disordersStressInfectious disease – hand foot and mouth / malaria / meningitis / measles / mumps / shinglesSubstance misuse – Including alcoholism & drug abuseSubstance misuse – Including alcoholism & drug abuseDetails of sickness absence: ..…………………………………………………………………………….…………………………....……………………………………………………………………………………………………………I declare that I have not worked during the above period of sickness and that the information given is correct.Signed: ………………………………………………….. Date: …………………………..Please pass this form to your manager for discussion at a return to work meeting.Manager: I confirm that I have met with the above named to discuss this period of sickness.Signed: ………………………………………………….. Date: ………………………….. ................
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