Sick (fit) note request

Is this your first fit note for this episode of illness?

Yes

No

Describe your illness and why you need a Fit Note: *

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

Please use this date format: DD/MM/YYYY

When should the fit note start? (It is not possible to use a future start date) *

Please use this date format: DD/MM/YYYY

When should the fit note end? (please note this may be amended by the clinician) *

Please use this date format: DD/MM/YYYY

Can your employer do anything to help you return to work sooner?

For example, work from home, reduced hours or tasks

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