FORM SA1

SICKNESS ABSENCE NOTIFICATION AND CONVERSATION RECORD FORM

CONFIDENTIAL

Section to be completed by the person taking the initial call

DATE OF CALL
TIME OF CALL
NAME OF EMPLOYEE
(or caller and relationship to employee)
EMPLOYEE CONTACT TEL. No
(If applicable, inform the employee their line manager or designated manager will return their call)
MESSAGE TAKEN BY (print name)
The form should be emailed to the employee’s line manager and business manager and copied to
NAME OF MANAGER(S) WHO THE FORM HAS BEEN EMAILED TO

Section to be completed by the line manager or designated manager

DATE CALL RETURNED
TIME CALL RETURNED
NATURE OF ILLNESS
Why is the employee unable to attend work?
Are they intending to consult a medical practitioner?
When?
If already visited e.g. GP, has a Fit Note been issued?
What is the date of signing?
What advice has been provided?
Is the absence due to an accident at work? Yes/No
Date of accident?
Has the accident been reported?
To whom?
When?
Brief details of accident.
Referral to OH required? / Yes/No
When does the employee expect to be back at work?
Inform the employee they must contact you each day of their absence for the first 7 calendar days.
If the line manager advises daily contact is not required, please document the reason why and record agreed contact arrangements.
Any Work commitments, meetings or training booked that need to be notified or covered by others?
CALL RETURN BY
When the form has been completed up to this stage, the form should be emailed to

Notes of future conversations with the employee can be documented below and the form forwarded to HR () with the Return to Work Documentation.

MANAGERS NAME
DATE
TIME
MANAGERS NAME
DATE
TIME
MANAGERS NAME
DATE
TIME
MANAGERS NAME
DATE
TIME
MANAGERS NAME
DATE
TIME

Continue if necessary.

Copy notes (if requested) provided to the employee? Yes No Date

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