Healthcare Templates Medical Forms Doctor Note TemplatesFillable Employee Illness Self-Certification

Get your Employee Illness Self-Certification in 3 easy steps

01 Fill and edit template
02 Sign it online
03 Export or print immediately

Who is this form for?

An employee who tells an employer, in writing and in their own name, about an absence because of illness. The employee completes and signs it; it is not a note from a doctor.

What does it contain?

The employee name; an optional payroll number and contact phone; the employer or HR department it goes to; the first day of the absence, the last day if it has ended, and the last day worked; an optional return date; the employee statement of inability to work due to illness; and the employee signature and statement date. It asks for no diagnosis. The form tells the employee: "Report your own absence and dates, follow employer procedures and retain a copy."

Employee Illness Self-Certification

Get your Employee Illness Self-Certification in 3 easy steps

Who is this form for?

What does it contain?

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