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    Adobe Scan 06 Jul 2021

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    Carl Childs
    This fit note from Mr. Childs' doctor assesses him as not fit for work for 1 month due to chronic pain and mental health illness. The doctor advises that with his employer's agreement, Mr. Childs may benefit from a phased return to work, altered hours or workplace adaptations. The doctor provides information on what the fit note means, how Mr. Childs can claim benefits if needed, and next steps to take regarding work and benefits.

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    Adobe Scan 06 Jul 2021

    Uploaded by

    Carl Childs
    132 views1 page
    This fit note from Mr. Childs' doctor assesses him as not fit for work for 1 month due to chronic pain and mental health illness. The doctor advises that with his employer's agreement, Mr. Childs may benefit from a phased return to work, altered hours or workplace adaptations. The doctor provides information on what the fit note means, how Mr. Childs can claim benefits if needed, and next steps to take regarding work and benefits.

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    This fit note from Mr. Childs' doctor assesses him as not fit for work for 1 month due to chronic pain and mental health illness. The doctor advises that with his employer's agreement, Mr. Childs may benefit from a phased return to work, altered hours or workplace adaptations. The doctor provides information on what the fit note means, how Mr. Childs can claim benefits if needed, and next steps to take regarding work and benefits.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    132 views1 page

    Adobe Scan 06 Jul 2021

    Uploaded by

    Carl Childs
    This fit note from Mr. Childs' doctor assesses him as not fit for work for 1 month due to chronic pain and mental health illness. The doctor advises that with his employer's agreement, Mr. Childs may benefit from a phased return to work, altered hours or workplace adaptations. The doctor provides information on what the fit note means, how Mr. Childs can claim benefits if needed, and next steps to take regarding work and benefits.

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    Statement of Fitness for Work Dota from page 1 of this form may be collected to learn about national potterns

    For social security or Statutory Sick Pay of sickness absence. Individuals will not be identified. Find out more at
    www.gov.uk/dwp/fit-note-data
    Patient's name Mr Childs Help getting back to work if you are employed
    If you've been off work or are likely to be off work sick for 4 weeks or more,
    I
    assessedyour 14/06/2021
    case on:
    you may be able to have a free ocCcupational health assessment. You will be able
    and, because of the Chronic pain.
    following condition(s; Mental Health illness.
    to discuss what advice and support you need to help you go back to work sooner.
    You can ask your GP or employer to refer you. For further information:
    i n England and Wales visit www.fitforwork.org or phone 0800 032 6235
    i n Scotland please visit www.fitforworkscotland.scot or phone 0800 019 2211.

    not fit for work.


    What your doctor's advice means
    I advise you that X you are
    You are not fit for work': Your health condition means thot you may not be able
    yoFeybe-ft4er-werktehing-stcouatef-
    the-following aduice-
    to work for the period shown. You can go back to work as soon os you feel able to
    and, with your employer's agreement, this may be before your fit note runs out.
    If available, and with your employer's agreement, you may benefit from: You may be fit for work': You could go back to work with the support of your
    employer. Sometimes your employer cannot give you the support you need and if
    ophosedreturnte werk ernendec duties this happens your employer will treat this form os though you are 'not fit for work.
    You don't need to get another of these forms from your doctor.
    akered-heurs wokplace edeptetions For more information please visit www.gov.uk and type 'patients and employees'
    Comments, including functional effects of your condition(s): into the search field.
    Fill in the Your details section. You can ask someone to do this for you if you
    cannot fill in your details yourself.
    Your details - Please use BLOCK CAPITALS

    Surname Mr Childs

    Other names Card Noman

    Address 8 Farman Close

    Salhouse
    This will be the case for 1 month Postcode NR13 6QD
    Norwich
    or from 14/06/2021 to 13/07/2021 Date of birth Mobile 07798 720389
    03/05/1976
    I witt/will not need to assess your fitness for work again at the end of this period. NI number
    (Please delete as opplicable)
    Doctor's signature What you need to do now
    I f you are employed: Please show this form to your employer. You could get
    StatutorySick Pay (SSP) which is paid by your employer. If your employer cannot
    SSP they will give you form SSP1 to claim benefits.
    Date of statement |14/06/2021 pay you
    You could claim benefits.
    Doctor's address
    If you are self-employed:
    Hoveton& Wroxham Medical Centre Ifyou are already claiming benefits: Please send this form to the office dealing
    Stalham Road With your claim.
    Norwich If you need to make a claim to benefits: Visit www.gov.uk/browse/benefits or
    NR12 8DU Tel:01603 782155 phone 0800 055 6688 (8am to 6pm Monday to Friday). Textphone users call
    Unique ID: Med 3 10/17 0800 023 4888.
    36119FD0-CD29-11EB-9087-659143959910

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