Sick (fit) note request

If the start date for this sick note is 3 or more days after today’s date, the request will be rejected. Please return to this form at a later date. Please also note that we cannot ‘forward date’ sick notes.

Start date for this sick note: *

End date for this sick note: *

Start date for this illness: *

First date you were not at work due to this illness:

Please use this date format: DD/MM/YYYY.

Total number of days you were ill or state ongoing:

Describe your illness and why you need a Sick / Fit Note:

If this is not your first sick note, why do you feel you need an extension to the sick note (eg, what impact is it having on your ability to work) and until what date? *

Are you requesting a: *

Not fit to work note

Phased return to work note

What discussions have you had with your employer relating to this? *

Please state your current occupation or state unemployed: *

Have you spoken to your work about whether they can facilitate altered/amended duties/hours? *

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