Employee's Statement of Sickness and SSP Claim

Please complete in full so that we can use this information to assess your eligibility for SSP

You must notify us of all periods of sickness lasting 7 days or less. We will use this information to assess your eligibility for Statutory Sick Pay (SSP). If your request is eligible you will receive SSP. If we cannot approve your request we will provide you with an SSP1 form which will explain why. You can use the SSP1 form to support a claim for Employment and Support Allowance.

If you remain absent after 7 days you must supply certification from your GP.

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* 1. First Name

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* 2. Surname

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* 3. Sickness details - please tell us the nature of your illness (do not just say 'off' or 'unwell' etc).

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* 4. Date sickness started

Date

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* 5. What was the first shift you missed due to sickness, date and start time?

Date / Start Time

Date

Time

AM/PM

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* 6. Last working day before sickness began

Date/Finish Time

Date

Time

AM/PM

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* 7. Was this sickness caused by an accident at work or industrial disease?

Yes

If yes, please provide details

Employee's Statement of Sickness and SSP Claim

Please complete in full so that we can use this information to assess your eligibility for SSP

Question Title

* 1. First Name

Question Title

* 2. Surname

Question Title

* 3. Sickness details - please tell us the nature of your illness (do not just say 'off' or 'unwell' etc).

Question Title

* 4. Date sickness started

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* 5. What was the first shift you missed due to sickness, date and start time?

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* 6. Last working day before sickness began

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* 7. Was this sickness caused by an accident at work or industrial disease?

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* 8. Place of work