United Guarding Sickness Form

United Guarding Sickness Form

Name: *
Employee number: *
Site number:
Date of absence / sickness (From): *
Date of absence / sickness (To): *
Details of absence / sickness: *
Did you consult a
medical practitioner?: *
If yes, please provide details of doctor's name, address, date of visit, treatment received and any current treatment:
Declaration:  

I certify that I have been incapable of working because of my absence/sickness on the dates shown above and that this information is true and accurate.
I acknowledge that false information will result in disciplinary action.
I hereby give my employer permission to verify the above information.

Signed : *
(Please type your full name)
Contract manager's name:
 
* Required  

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