Fitness for work / Sick note Request

When do I need a fit note?

7 days off sick or less

If you're off work sick for 7 days or less, your employer should not ask for medical evidence that you've been ill. Instead they can ask you to confirm that you've been ill. You can do this by filling in a form yourself when you return to work. This is called self-certification.

More than 7 days off sick

If you're off work sick for more than 7 days, your employer will usually ask for a fit note (or Statement of Fitness for Work) from a GP or hospital doctor. Fit notes are sometimes referred to as medical statements or a doctor's note.

For more information please visit; https://www.nhs.uk/common-health-questions/caring-carers-and-long-term-conditions/when-do-i-need-a-fit-note/

Your Details

Title

First Names

Surname

Date of BirthDD/MM/YYYY

NHS Number (if known)

Your Contact Details

Home Address

Postcode

Telephone

Mobile

E-mail Address

Details

Have you had a fit / sick note for this condition before?

If yes, please provide details of the previous note and why you require an additional note

If you have not had a note previously, provide details of your condition and why you require a fit / sick note

Are you fit for work as long as there are alterations to your workplace (e.g. adaptations to the workplace or working hours)?

If yes, please provide details

What date would you like the Fit (“sick”) note to start? Please enter as DD/MM/YYY.(This should be the first date you were not at work, or the day after your last Fit (Sick) note ended)

What date would you like the Fit(“sick”) note to end? You will be covered until the end of this day. Please enter as DD/MM/YYY.(This is the date when you think you will be ready to work again. Please add a suggestion and this will be reviewed by your GP practice)

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