Self Certification and Return to Work

Self Certification and return to work

Your Name*
First Last
Date you became unfit for work*
Date Format: DD slash MM slash YYYY
Date you became fit for work*
Date Format: DD slash MM slash YYYY
Reason for absence*
Who within Libertatem Healthcare did you notify of your absence?*
What date did you notify us?*
Date Format: DD slash MM slash YYYY
Have you consulted a GP or visited a hospital?*
- Yes
- No
Have you been prescribed medication?*
- Yes
- No
Were you issued with a fitness to work certificate?*
- Yes
- No
Was the absence a result of an accident at work or as a result of industrial disease?*
- Yes
- No
If yes, then please give details
Have you reported the accident?
- Yes
- No
Please confirm that you are fit to return to your normal duties*
- I confirm
- I require support with returning to my normal duties
- I am unable to return to work
Please indicate the support you require from us to assist you to return to your normal duties
I declare that the information given is correct - Signature*
Today's date*
Date Format: DD slash MM slash YYYY

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Libertatem
Head Office Libertatem Healthcare Group Indigo House Fishponds Road Wokingham RG41 2GY
01189 730006
info@libertatemhealthcare.co.uk

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