Fit (Sick) Note

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Have you read and understood our sick note policy and procedures document?: *

Please go and read and understand before continuing.

Please do not continue with this form until you have read the guidance.: *

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Personal Details

Please provide your details to help us find your record. If you are filling this in on behalf of someone else, please enter their details.

Gender: *

Please double check you've entered the correct email address

May be used to identify you

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Employment

What is your employment status?: *

Is your employer aware of your sickness?: *

Is your employer supportive?: *

Do you have an occupational health policy and department?: *

Are you claiming or intending to claim benefits?: *

Reason for Fit Note

What is this sick note request in relation to?: *

GP Consultation

Did you discuss sick note with the clinician?: *

Did the clinician agree with your request?: *

Is this your first sick note request?: *

Is this a follow-on request?: *

If so, was this plan agreed with the clinician?: *

Situation that you have not yet informed the doctors about

Hospital Treatment

It is the responsibility of the hospital doctor to issue a sick note.

Please stop using this form and contact the hospital doctor.

Please do not continue with this form: *

Hospital or Community Specialist

It is the responsibility of the specialist to issue a sick note.

Please stop using this form and contact the specialist.

Please do not continue with this form: *

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Further Questions

Is this sick note in relation to any of the following?: *

Have you discussed the issues with your line manager or human resources?: *

Is there a process in place of resolving the underlying issue?: *

Have you involved the appropriate agencies in resolving the issues such as trade unions, occupational health departments and legal teams?: *

Do you have any urgent issues to deal with before the funeral?: *

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Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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Fit (Sick) Note

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