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Self-Certification Sickness Form (UK)

Self-Certification Sickness Form

EMPLOYEE SELF-CERTIFICATION SICKNESS FORM

This form is completed by the employee to self-certify a period of sickness absence of up to seven consecutive calendar days, in accordance with the Social Security (Medical Evidence) Regulations 1976 (SI 1976/615) as amended by the Social Security (Medical Evidence) and Statutory Sick Pay (Medical Evidence) (Amendment) Regulations 2022. For absences exceeding seven calendar days, a Statement of Fitness for Work (fit note) from a registered medical practitioner is required.

Date of Declaration: [Declaration Date]

SECTION 1 — EMPLOYEE DETAILS

Full Name: [Employee Name]

Employee / Payroll Number: [Employee Number]

Department / Team: [Department]

Line Manager: [Manager Name]

Data Protection Notice: The personal and health information contained in this form is special category data within the meaning of Article 9 of the UK GDPR and the Data Protection Act 2018. It is processed by the employer on the basis of Article 9(2)(b) UK GDPR (employment law obligations) and Article 6(1)(b) UK GDPR (performance of the employment contract) for the purposes of managing the employee's absence, administering Statutory Sick Pay in accordance with the SSP (General) Regulations 1982, and complying with health and safety obligations under the Health and Safety at Work etc. Act 1974. This form will be retained on the employee's confidential HR record and will not be disclosed to third parties except where required by law.

SECTION 2 — ABSENCE PERIOD

First Day of Illness: [First Day of Illness]

Last Day of Absence: [Last Day of Illness]

Date of Return to Work: [Return to Work Date]

Total Working Days Lost: [Working Days Lost]

SSP Note: Statutory Sick Pay (SSP) is payable under the Social Security Contributions and Benefits Act 1992 and the SSP (General) Regulations 1982 (SI 1982/894) from the fourth qualifying day of incapacity (i.e. after three waiting days). The current SSP rate is reviewed annually. Qualifying days are the days of the week on which the employee is contracted to work. Self-certification covers the first seven calendar days of absence; a fit note is required from the eighth calendar day.

SECTION 3 — REASON FOR ABSENCE

Nature of Illness: [Absence Reason]

SECTION 4 — GP OR HEALTHCARE PROFESSIONAL CONSULTATION

GP or Healthcare Professional Consulted: [Gp Consulted]

SECTION 5 — STATUTORY SICK PAY (SSP) DECLARATION

The employee acknowledges that Statutory Sick Pay may be payable in accordance with the Social Security Contributions and Benefits Act 1992 and the SSP (General) Regulations 1982 (SI 1982/894) for the qualifying days of the absence period recorded in Section 2. SSP is payable at the current statutory rate from the fourth qualifying day of incapacity and is subject to the employee meeting the earnings threshold and not having exhausted the maximum entitlement period. The employer may also pay occupational sick pay (OSP) in accordance with the terms of the employment contract or the company sickness absence policy. The employee authorises the employer to process the self-certified absence period for payroll purposes in accordance with the Employment Rights Act 1996, section 13 (authorised deductions from wages).

EMPLOYEE DECLARATION

I declare that the information provided in this self-certification form is true and accurate to the best of my knowledge. I was unable to work due to illness for the period stated in Section 2 of this form. I understand that providing false or misleading information on this form may constitute a disciplinary offence under my employer's Disciplinary Policy and may, in cases of fraudulent claims for Statutory Sick Pay, give rise to criminal liability under the Fraud Act 2006.

Employee Name: [Employee Name]

Employee Number: [Employee Number]

Department: [Department]

Date: [Declaration Date]

MANAGER ACKNOWLEDGMENT

I acknowledge receipt of this self-certification form. I confirm that the absence period recorded has been entered into the attendance management system and that the appropriate payroll instructions have been raised. Where the employee's absence pattern, duration, or stated reason for absence raises concerns under the company absence management policy, a return to work interview has been or will be arranged in accordance with best practice guidance from the Advisory, Conciliation and Arbitration Service (ACAS).

Manager Name: [Manager Name]

LEGAL NOTICE

This form is completed pursuant to the Social Security (Medical Evidence) Regulations 1976 (SI 1976/615) as amended; the SSP (General) Regulations 1982 (SI 1982/894); the Social Security Contributions and Benefits Act 1992 (SSP provisions); and the Employment Rights Act 1996, section 13 (protection of wages). The employer's obligations in relation to reasonable adjustments for disabled employees are governed by the Equality Act 2010, sections 20 and 21. Where an employee's recurring or long-term absence may indicate a disability, the employer should seek an occupational health assessment and consider appropriate workplace adjustments before taking any management action. This document is governed by the laws of England and Wales.

Employee

________________

Signature

Date: ________________

Line Manager

________________

Signature

Date: ________________

Maintained by Vladislav Sergienko, Founder·Template last modified: ·Report an error

What Is a Self-Certification Sickness Form (UK)?

A Self-Certification Sickness Form in the United Kingdom records an employment request, entitlement, or HR particular and the information the parties need to action it, as regulated by the Employment Rights Act 1996.

The legal foundation for self-certification is the Social Security (Medical Evidence) Regulations 1976 (SI 1976/615) as amended, which prescribe the circumstances in which medical evidence is required and when an employee's own declaration is sufficient. For absences of seven calendar days or fewer, an employee's personal statement — typically made through a self-certification form — is accepted as adequate evidence of incapacity. A fit note from a registered healthcare professional is only required from the eighth consecutive calendar day of absence.

For Statutory Sick Pay (SSP) purposes, the relevant legislation is the Social Security Contributions and Benefits Act 1992 and the SSP (General) Regulations 1982 (SI 1982/894). SSP is payable by the employer from the fourth qualifying day of incapacity — the first three qualifying days (known as waiting days) are not paid unless the employer has a more generous occupational sick pay scheme. Qualifying days are the days on which the employee is contracted to work. The self-certification form creates the contemporaneous record needed to process SSP and any occupational sick pay accurately and in compliance with section 13 of the Employment Rights Act 1996, which restricts unauthorised deductions from wages.

From 1 July 2022, the range of healthcare professionals authorised to issue fit notes was expanded by the Social Security (Medical Evidence) and Statutory Sick Pay (Medical Evidence) (Amendment) Regulations 2022 to include registered nurses, occupational therapists, pharmacists, and physiotherapists. This change means that, for absences requiring a fit note, employees have a wider range of healthcare professionals from whom they can obtain the required documentation, reducing the burden on GP services.

Health information collected on a self-certification form constitutes special category data under Article 9 of the UK GDPR and the Data Protection Act 2018. Employers must process this data lawfully, with appropriate security measures, and retain it only for as long as necessary for the purpose for which it was collected — typically for the duration of employment and for a reasonable period thereafter for legal and statutory purposes.

The legal framework governing the Self-Certification Sickness Form (UK) in United Kingdom draws on several key statutes and regulatory bodies. Under the Employment Rights Act 1996, the Employment Tribunal adjudicates workplace disputes. Section 94 of the Employment Rights Act 1996 provides the right not to be unfairly dismissed. The Advisory, Conciliation and Arbitration Service (ACAS) provides early conciliation under Section 18A of the Employment Tribunals Act 1996. The UK GDPR and Data Protection Act 2018 govern personal data handling. HM Revenue and Customs (HMRC) administers PAYE and National Insurance contributions under the Income Tax (Earnings and Pensions) Act 2003. Parties executing a Self-Certification Sickness Form (UK) in United Kingdom should confirm the document reflects current law, including any amendments enacted since the original drafting date. The Employment Rights Act 1996 sets the foundational requirements.

When Do You Need a Self-Certification Sickness Form (UK)?

A Self-Certification Sickness Form should be completed by the employee as soon as they return to work following a period of absence due to illness lasting up to seven consecutive calendar days, or — where the employer's policy requires it — before the employee returns, if the form can be completed remotely. Many employers require the form to be submitted on the first day of return as part of a formal return to work interview process.

The form is needed for every period of self-certified absence, including isolated single-day absences. Whilst one day of absence may seem minor, a consistent record of short-term absences is important for several reasons. First, SSP eligibility may be affected by the pattern of absences — under the SSP (General) Regulations 1982, a Period of Incapacity for Work (PIW) consists of four or more consecutive qualifying days of sickness, and separate periods of sickness that are no more than eight weeks apart may be linked as a single PIW for SSP purposes. Second, repeated short absences may be indicative of an underlying health condition, and maintaining a record allows the employer to identify patterns that warrant a more supportive response — such as an occupational health referral — and to fulfil the employer's duty of care under the Health and Safety at Work etc. Act 1974.

The form is particularly important where an employee's sickness absence may be connected to a disability within the meaning of the Equality Act 2010. A physical or mental impairment that has a substantial and long-term adverse effect on a person's ability to carry out normal day-to-day activities is a disability for the purposes of the Act. Where an employee's absences are related to a disability, the employer has a duty under sections 20 and 21 of the Equality Act 2010 to make reasonable adjustments to remove or reduce any disadvantage the employee faces because of the disability. A pattern of self-certification forms citing the same type of condition should prompt the employer to consider whether an occupational health referral is needed.

A self-certification form is also needed for payroll purposes. The employee's declaration of the dates and duration of their absence provides the documentary evidence needed to process SSP or occupational sick pay accurately, in compliance with the employer's obligations under section 13 of the Employment Rights Act 1996. Without a completed form, the employer may face disputes about the level of pay due during the absence and may lack the records needed to respond to any Employment Tribunal claim.

Finally, under the ACAS Code of Practice on Disciplinary and Grievance Procedures, a documented return to work process — which typically includes a return to work interview and completion of a self-certification form — is recommended best practice. If an employer later needs to take formal absence management action, evidence that a consistent and fair process was followed for all employees will be important in defending any potential claim of unfair treatment.

What to Include in Your Self-Certification Sickness Form (UK)

A well-drafted Self-Certification Sickness Form for use in England and Wales should contain all the elements needed to satisfy the employer's legal and administrative obligations whilst respecting the employee's right to privacy and freedom from discrimination.

The employee identification section records the employee's full name, payroll or employee reference number, department, and line manager. The payroll number is particularly important because it links the form to the correct payroll record, confirming that SSP and occupational sick pay are processed accurately.

The absence period section is the core of the form. It must record the first day of illness, the last day of absence, the date of return to work, and the total number of working days lost. The distinction between calendar days and working days matters: the seven-day self-certification window is measured in consecutive calendar days (including non-working days), while SSP is calculated by reference to qualifying days, which are the contracted working days. Both figures must therefore be recorded accurately.

The reason for absence section provides a structured way for the employee to describe the nature of their illness without requiring a medical diagnosis. A pre-defined list of categories — such as cold or flu, musculoskeletal pain, mental health, stomach illness, or headache and migraine — enables the employer to collect consistent data for absence monitoring purposes whilst minimising the risk that employees feel pressured to disclose more than is necessary. Since health information is special category data under Article 9 of the UK GDPR, the form should include a data protection notice explaining how the information will be used and retained.

The GP or healthcare professional consultation section asks the employee whether they consulted a GP, pharmacist, or other healthcare professional during the absence. This field is optional and is included to assist employers who may need to make reasonable adjustments or refer the employee for occupational health assessment. Where a GP was consulted, recording the GP's name and practice allows the employer to seek further information (with the employee's consent) if a long-term condition is disclosed.

The employee declaration section contains the formal statement by which the employee confirms that the information is accurate and that they were genuinely unable to work due to illness during the period stated. A false declaration made to obtain SSP or occupational sick pay may constitute a criminal offence under the Fraud Act 2006 and a disciplinary offence under the employer's Disciplinary Policy — this should be made clear on the form.

The manager acknowledgment section confirms that the line manager has received and reviewed the form, entered the absence into the attendance management system, and — where appropriate — conducted a return to work interview. Countersignature by the manager provides an additional layer of accountability and confirms that absence is consistently recorded across the organisation. The forms-legal.com Self-Certification Sickness Form (UK) template covers the mandatory elements under Employment Rights Act 1996.

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Forms Legal. (2026). Self-Certification Sickness Form (UK) (United Kingdom) [Legal document template]. Forms Legal. https://forms-legal.com/uk/employment/hr-forms/self-certification-sickness-uk

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BibTeX
@misc{formslegal-self-certification-sickness-uk,
  author       = {{Forms Legal}},
  title        = {Self-Certification Sickness Form (UK) (United Kingdom)},
  year         = {2026},
  howpublished = {\url{https://forms-legal.com/uk/employment/hr-forms/self-certification-sickness-uk}},
  note         = {Free legal document template. Based on Employment Rights Act 1996}
}

Frequently Asked Questions

Based on Employment Rights Act 1996 — Template last modified June 2026Verify the source →

This template is provided for informational purposes only and does not constitute legal advice. Laws vary by jurisdiction and change over time. Consult a qualified attorney for advice specific to your situation.Full disclaimer

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