[{"id":"b2611a96-fd6a-4bc6-9c04-3b11c585f30e","order":1,"text":"STATEMENT OF SICKNESS","fontSize":"22","textAlign":"center","bold":true,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"acd569ef-b7fa-4420-9049-90e550c28ddb","order":2,"text":"Employee Self-Certification of Sickness Absence (SC2-Style)","fontSize":"15","textAlign":"center","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"1ad2f934-4c86-4981-ba44-dde3f60816d2","order":3,"text":"Employer / Organisation: [Employer / organisation name]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"0ced6c81-ddbd-42b9-914b-ac461aa844d0","order":4,"text":"Reference / Case no.: [Reference]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"8799995e-5211-4af3-93d7-6c13999af863","order":5,"text":"This form enables an employee to self-certify a period of sickness absence of up to seven (7) consecutive calendar days, in accordance with the Statutory Sick Pay (Medical Evidence) Regulations 1985 and Statutory Sick Pay (General) Regulations 1982. No doctor's fit note is required for absences of seven calendar days or fewer. The information recorded below is used to administer pay, including Statutory Sick Pay (SSP) where applicable, and to confirm in writing the dates of absence agreed between the employee and the employer for payroll, handover and resource-planning purposes.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"b7bb0766-9fc2-4de6-86bb-b1d16ef3e6fb","order":6,"text":"PART A — EMPLOYEE DETAILS","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"10"},{"id":"a1328713-f1df-4ab7-8dbd-8a96380d23d1","order":7,"text":"Full name of employee: [Full name]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"fd41548e-4b31-4eff-9688-21e9b570936e","order":8,"text":"Job title: [Job title]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"0541ba09-440c-408d-97c3-c5e92fbd6c8e","order":9,"text":"Department / team: [Department]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"574e05dc-c8fd-49af-9dbe-ff79db0d289c","order":10,"text":"Payroll / employee number: [Payroll number]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"9223ad77-cf82-448f-a90b-593dd088edb3","order":11,"text":"National Insurance number: [NI number]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"0500fa02-f3da-4f42-ac88-982ba9163b04","order":12,"text":"PART B — STATEMENT OF SICKNESS","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"10"},{"id":"15525a73-2bd0-4b15-9ed2-f4a4af3cf6e5","order":13,"text":"I, [Full name], confirm that I was unable to attend work because of sickness during the period set out below.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"70d41e06-2327-4a9d-b258-d6aa49b5ca94","order":14,"text":"First day of sickness (first calendar day of incapacity): [First day]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"fbdaf695-8f23-4afe-bfc4-60678ce25a10","order":15,"text":"Last day of sickness covered by this certificate: [Last day]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"5a1c675c-857d-4a50-9e21-bfbe5c561dcd","order":16,"text":"Total number of calendar days of sickness in this period: [Number of days]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"c4d54510-db70-4569-ab50-d6d50202d83c","order":17,"text":"I confirm that this self-certification covers the period from [First day] to [Last day] inclusive, being seven (7) consecutive calendar days or fewer.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"82030069-618d-4592-9e63-3861e804a884","order":18,"text":"Were you scheduled to work on the first day of sickness, and did you work any part of that day before going home? [Yes / No]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"b314ae0c-9ad9-4aa6-949f-67e7076ae5a8","order":19,"text":"Nature of sickness (please describe your symptoms or condition in general terms): [Description of illness]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"24af2159-759a-4b04-9744-bec380c8ff63","order":20,"text":"Is your sickness, in your view, caused by or connected to your work? [Yes / No]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"7e2398d9-cd7d-4577-a267-3853269f2daf","order":21,"text":"If yes, please give brief details of how the sickness relates to your work: [Work-related details]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"c3ea8662-2807-4579-8e20-5d19adb855ab","value":"No","type":"remove","operator":"="}]},{"id":"011a5b8b-5e12-4545-b9b5-df17a6a3e184","order":22,"text":"Did the sickness arise from an accident? [Yes / No]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"ba7132af-5678-48b2-982c-fd688389d449","order":23,"text":"If yes, please give brief details of the accident (date, place and circumstances): [Accident details]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"37be8178-4d2f-4301-87aa-86a56f263f16","value":"No","type":"remove","operator":"="}]},{"id":"52debca6-cdd8-43fa-8f3a-2633ae194c28","order":24,"text":"Did you consult a doctor or other healthcare professional about this sickness? [Yes / No]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"732cfa1c-5713-4ee9-8338-900015fca3b7","order":25,"text":"PART C — STATUTORY SICK PAY AND NOTIFICATION","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"10"},{"id":"63a46744-94b7-40ea-9260-29eefa502678","order":26,"text":"Is this period of sickness related to pregnancy? [Yes / No]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"282fd4ca-d7c6-44dd-a71b-8ea899145e1b","order":27,"text":"This question is asked because pregnancy-related absence may be treated differently for pay and may engage separate maternity protections. It does not affect your right to self-certify this absence.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"1f6b59bd-5783-457b-abd0-db556905ee83","order":28,"text":"Date on which the employer was first notified of this absence: [Notification date]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"5dc8f0cb-0c5c-445d-aaa8-66bfa27cbf2f","order":29,"text":"Method by which the employer was notified: [Notification method]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"92bd6610-4687-47ac-8403-bbaaed9d9d80","order":30,"text":"PART D — EMPLOYEE DECLARATION","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"10"},{"id":"1d82529c-ea85-4881-8f67-4f543f3edfdc","order":31,"text":"I declare that the information given on this form is true and complete to the best of my knowledge and belief. I understand that this statement is made for the purpose of claiming any pay due during sickness, including Statutory Sick Pay where applicable, and that knowingly giving false information may result in disciplinary action and, where relevant, the recovery of any overpayment. I understand that the personal data provided will be processed by my employer for the administration of absence and pay, in accordance with the UK General Data Protection Regulation and the Data Protection Act 2018.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"9e688bee-48af-43f9-938d-61d95cf566a1","order":32,"text":"Signed (employee): [Employee signature / name]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"36967fd4-1aee-4c3d-968d-72af417eb93e","order":33,"text":"Date of declaration: [Date]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"0ab5825e-8cae-4a53-932f-32dd6cffcc01","order":34,"text":"PART E — FOR EMPLOYER USE ONLY","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"10"},{"id":"1e6845c5-d5ef-4a28-ab25-396592d83f14","order":35,"text":"This part is completed by the employer or the employee's line manager to record the absence and to confirm, in writing, the dates of sickness absence agreed for payroll, handover and planning purposes. Completing this part avoids any later dispute as to dates that were only discussed informally.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"d73ff619-3434-4c9e-8cb6-9315378d1642","order":36,"text":"Approved / recorded first day of absence: [Approved first day]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"3cca932e-699f-4c27-81af-a526694dd6f0","order":37,"text":"Approved / recorded last day of absence: [Approved last day]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"94554020-9772-400c-a1ed-411d862e79bd","order":38,"text":"Statutory Sick Pay decision for this period: [SSP decision]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"b1d10bd4-af35-4ec8-8ca0-1701a7824f75","order":39,"text":"Has a return-to-work discussion been held with the employee? [Yes / No]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"de029056-7a28-4472-9c30-baffd425ca77","order":40,"text":"Date of return-to-work discussion: [Return-to-work date]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"fd9d644d-21fd-4f78-8d0d-dd11155103f0","value":"No","type":"remove","operator":"="}]},{"id":"b85716f4-5c80-4351-8879-3d1c890012e8","order":41,"text":"Confirmed by (manager / authorised signatory): [Manager name]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"e18cae0f-9107-402c-be5d-b17ecbc11cf0","order":42,"text":"Position / role: [Manager position]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"4","cflou":false,"active":true},{"id":"6e9bdbec-b306-49c2-8d28-497fe4cc3583","order":43,"text":"Date confirmed: [Date]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"c6615910-b36c-4bbc-82cf-049ff4d45ac5","order":44,"text":"The employer, [Employer / organisation name], confirms that the dates recorded above are the dates of sickness absence agreed in respect of [Full name] for the purposes of pay and record-keeping. This written confirmation supersedes any informal or verbal discussion of those dates.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"5f598122-5887-4b20-93ea-e4443c2a5398","order":45,"text":"NOTES","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"10"},{"id":"0c1de37d-e651-4473-a2df-beb0589998e3","order":46,"text":"Self-certification applies to sickness absence of seven (7) consecutive calendar days or fewer (including non-working days, weekends and bank holidays). For absences of more than seven calendar days, a fit note (Statement of Fitness for Work) from a registered healthcare professional is normally required. Statutory Sick Pay is payable, subject to the qualifying conditions, in respect of qualifying days within a period of incapacity for work, after the applicable waiting days. This document does not constitute legal advice; where an employer operates an occupational sick pay scheme, the terms of that scheme apply in addition to the statutory framework.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"2b241e07-daf2-4d1f-ad06-0132f6f05dae","order":47,"text":"The employee named in this statement is [Full name]. This completed statement should be retained by the employer with the relevant pay and absence records.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"0","cflou":false,"active":true}]