Sickness Notification Form (7 days or less)

Sickness Notification Form

This online Sickness Notification Form is to be completed by all Primary Care Knowsley employees when notifying the organisation of sickness-related absences. Before completing this form, employees must first contact their line manager directly to inform them of their absence. Upon receiving instructions from the line manager, employees should proceed with filling in the form to officially record their sickness leave. The form ensures accurate documentation of the absence, allowing for appropriate follow-up and planning. Failure to complete the form after manager instruction may result in unrecorded leave.

Name:

First Last

Primary Location of Employment:

Select the location where you are primarily based or assigned for work. This should reflect the main site or office you work from, even if your role involves travel or remote work. If you regularly work across multiple locations, choose the one you consider your home base.

Job Role:

Clinical

Administration

Absence reported to (Name):

First Last

You are required to provide the name and designation of the person you informed of your absence. This needs to be a manager senior to yourself.

Role

Date Reported:

Time Reported:

Communication Type:

First Date of Absence:

Enter the first day you were unable to attend work due to sickness. This should be the exact date your illness or injury started affecting your ability to work, even if it was a non-working day (such as a weekend or holiday).

Contact Phone Number:

Provide the best phone number where you can be reached during your absence. This should be a number where your employer can contact you if any clarification or updates are needed regarding your sickness notification.

What is the nature of your absence/illness?

Briefly describe the reason for your absence, including the symptoms you are experiencing or the type of illness or injury. If applicable, indicate whether this is a recurring condition. This information helps your employer understand the nature of your illness and assess the expected duration of your absence. (Please avoid sharing sensitive medical details unless required.)

Have you sought medical advice?

Yes

Did you know that you can access a GP by utilising your WPA benefit package? (Salaried Employees Only)

Yes

This is a reminder that, as a salaried employee, you may have access to private GP services through your WPA benefit package. These services can offer quicker consultations and medical advice, which may help you manage your illness more effectively. For more information and to access these services, please use the link at the top of this page.

What steps have you taken to manage your absence/illness?

Describe any actions you have taken to address or manage your condition. This could include seeking medical advice, taking prescribed medication, or following home-care recommendations.

Self Certification Sick / Fit Note for less than 7 days (Upload) Optional

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.

If you have been ill for 7 days or less you don’t need to see a Doctor. You can complete the Self Certification form yourself. The link to download the form is at the top of this page. Please download/print it, fill it in and Send back using the file upload option. You do not need to see a Doctor to self certify.

Will you be well enough to return to work tomorrow?

Yes

Unsure

Indicate whether you expect to be fit enough to resume your duties by tomorrow. If you’re unsure, provide your best estimate based on your current condition and any medical advice you have received. This information helps your employer plan for staffing needs during your absence.