ICSG Sickness Absence Notification Form

Employee Absence Details

Employee name*

Job title*

Line manager*

First date of absence*

Last date of absence*

Date returned to work

Total working days absent*

General reason for absence*

Medical Details

Temporary workplace support or restrictions required

Employee Declaration

The information provided is true and complete to the best of the employee’s knowledge. The employee understands that deliberately false information or falsified medical evidence may result in disciplinary action.

I confirm

Employee name as signature*

Date of declaration*

Manager Review

Manager name/signature

Manager review date