Sickness Absence Self-Certification Form: CONFIDENTIAL

Page 1: I certify that I was incapable of working due to sickness/injury

Name in full
(block capitals)

GILANG NUSA PHALA

Department / Project
(block capitals)

NGAWI KERTOSONO TOLL ROAD

Staff number

68532

1st day of absence

Date I last worked

22 Jan. 15

I restarted work on

26 Jan. 15

The reason for my incapacity was Fever

Have you had time off work for the same condition with the last 12 months? Yes
Did you consult your doctor whilst you were absent? Yes
Are you anticipating further periods of absence because of this condition? Yes
Please estimate the number of days sickness absence in the last 12 months? 7 days
How many separate sickness periods have you suffered in the last 12 months? 4 times
Is the reason for this absence work related? YES / NO* (please delete as appropriate)
If you answered Yes to the above please provide further details: .
.

I certify that the above information is correct to the best of my knowledge and claim any
sickness pay to which I may be entitled. I understand that the deliberate provision of
false information may result in disciplinary action being taken against me.

Signed Staff Member..

Date ..

Countersigned . Date ...

(Head of Department / Project Manager)
Manager Comments (If no Return-to-work interview required, alternatively complete page 2)
....
....
.

Page 2: Return-to-Work Interview: To be completed by Line Manager meeting the

employee
1.

Did the employee comply with the Companys Sickness Absence

Policy in terms of reporting the absence and providing a fit note if
the absence lasted more than 7 calendar days?

Yes

No

Was the reason for absence work-related? If No, go to Q.3

Yes

No

Was the absence due to an injury or accident at work?

Yes

No

If yes, were the reporting procedures relating to Health & Safety

at work followed i.e. was the Group Accident and Reporting
System completed?

Yes

No

If no, was the absence attributed to work related stress?

Yes

No

Was the absence attributed to personal issues?

Yes

No

If so, is employee willing to discuss these? Please give details. If

appropriate provide the CiC information.

Yes

No

Did the employee seek advice from their G.P./other health

consultant? If no, what action did the individual take?
If yes, are they prepared to discuss the advice with you, if not a
member of HR/ someone of the same gender?

Yes

No

Advise who will speak with employee and confirm arrangements

made.

NAME:

5.

Is further medical treatment required? How will this impact on

attending work? Give details.

Yes

No

6.

Is there anything that our First Aiders should be made aware of?

Yes

No

Yes

No

If no, state reasons given and action taken/advice given. Have all
recommendations been considered/implemented? Give details.

2.

Give details and action taken/advice given, if any.

Go to Q.4
3.

4.

If yes, give details.

7.

Is there anything else we should be made aware of?

If yes, give details.

Signed:

Date:

Name of Manager / Project Manager:

I consent to the information in this form being obtained and recorded by MM Indonesia in connection with my
employment.
Signed:

Date:

Total number of days absent from work in last 12 months:

Name of Employee: