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Printable Self Certification Form
Time in 24 hours)
Title – enter MR, MRS, MISS, MS, or other title
Was your sickness caused by an accident at work or an
industrial disease?
National Insurance number
Date of birth DD MM YYYY
No
Yes
If you answered ‘Yes’, you may be able to get Industrial Injuries
Disablement Benefit. If you want information about claiming
this benefit, ask at any Jobcentre Plus office or go to
www.dwp.gov.uk
Clock or payroll number
Signature
About your sickness. Please give brief details
Date DD MM...
Show details
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