Sickness enquiry form

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If you have been off sick and need advice, please read your local sickness policy and our sickness advice guide, as it is highly likely you will find what you need there. Our guide includes information on fit notes, meetings, occupational health, returning to work, and more.

If you have been told by Occupational Health or a medical professional that you have a disability, see our guidance for the definition of disability, and how the Disability Discrimination Act protects you.

If you have been invited to an informal meeting, or it is your first formal sickness meeting, we may not need to attend. However, it is important that we properly assess your situation, so please complete all the details below.

Please ensure that that you have read our guidance, and that you complete all sections in full. This will enable us to assess your situation and arrange appropriate advice and support for you without delay.

Please confirm that you have read our advice

Contact details

Full name: 茄子视频 membership number: Address: Best contact number:

Please note that 茄子视频 Direct will not usually call you. Where an onward referral is required, provided you were in the correct category of membership on the date that the first sickness absence period under review started, we will provide your contact details to your local regional/country office.

Do you give us your consent to pass on this information? Yes No Can we leave you a voicemail? Yes No Can we contact you on this matter by email? Yes No If we need to pass your enquiry to your local 茄子视频 office or a specialist 茄子视频 department, would you like any emails from them to be password protected? Yes No Email address you would like us to reply to Please confirm the email address you would like us to reply to Please list any times that you are unavailable for calls during the next week (9am-5pm):

Employment details

Please write out in full, don't use acronyms.

Place of work Employer On what date did you start working with your current employer? Ward, department or team Job category Job title Weekly contracted hours Do you have any meetings scheduled? Yes No If yes, please give date, time and location: Is this a formal or informal meeting? Formal Informal Not sure Who will be in attendance? Are you already being supported by a rep? Yes No If yes, please include details below: Are you in the UK on a visa? Yes No If yes, please include details below (including how long you have been in the UK and when your visa expires):

Sickness

THIS SECTION IS VERY IMPORTANT.

Whilst we do not require in-depth detail at this stage, you must give us enough information so that we do not need to contact you for further information, as this may cause unnecessary delay in arranging support.

Please note, we do not need to see the correspondence between yourself and anyone else involved at this stage; however, you should retain all documentation as your local 茄子视频 team may require this.
What was the start date of the first sickness absence period that is under review? What was the reason for this absence? Please give the dates, duration, and reason for any subsequent sickness periods under review: Were any of these absences work-related, for example, due to a workplace injury or workplace stress? Yes No If yes, please provide details: If your absence is due to an injury sustained due to the fault of someone else, would you like 茄子视频 Law to contact you to discuss a potential personal injury claim? Yes No Not applicable If yes, please provide details of the injury/symptoms: Have you been told by Occupational Health or a medical professional that you have a disability? Yes No If yes, please provide brief details: Are you currently off sick? Yes No When do you anticipate returning to work? Will you be fit to return to your existing role? Yes No Have any recommendations been made by Occupational Health or another health professional? Yes No If yes, please provide brief details: Is your employer supporting these recommendations? Yes No Partly

Can we update your personal details if any of the above does not match the data we currently hold on your record? Yes No

By submitting this form, you are giving the 茄子视频 permission to contact you about your submission.

You can control the information you receive from the 茄子视频 by updating your preferences at My茄子视频.

We do not update your contact details unless you ask us to. The best way to check and update the details we hold for you is by visiting My茄子视频.

The information you provide in this form will be stored by the 茄子视频.

Protecting your privacy is very important to us. Please view our privacy policy to find out more about the information we collect and how it is used.

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