Statement of Fitness for Work What your advice means
For social security or Statutory Sick Pay
‘You are not fit for work’ Patient’s name Mr, Mrs, Miss, Ms Thomas George Williams Your health condition means that you may not be able to work for the ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ period shown. You can go back to work as soon as you feel able to and, with I assessed your case on: 31 / 05 / 2024 your employer’s agreement, this may be before your fit note runs out. and, because of the ‘You may be fit for work’ Increased Anxiety following condition(s): You could go back to work with the support of your employer. Sometimes your employer cannot give you the support you need and if this happens your employer will treat this form as though you are ‘not fit for work’. You do not need to get another of these forms. I advise you that: X you are not fit for work. For more information please visit www.gov.uk and type ‘fit note guidance you may be fit for work taking account of for patients and employees’ into the search field. Fit note guidance for ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ the following advice: ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ employers is also available. If available, and with your employer’s agreement, you may benefit from: amended duties Data from page 1 of this form may be collected to learn about national a--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- phased return to work -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- patterns of sickness absence. Individuals will not be identified. Find out altered hours workplace adaptations --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- more at www.gov.uk/dwp/fit-note-data Comments, including functional effects of your condition(s):
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, Mrs, Miss, Ms ----------------------------------------------------------------------------------------- WILLIAMS --------------------------------------------------------------------------- -----------------------------------------------------------------------------------
Other names THOMAS GEORGE
Address C/O THE COLNE PRACTICE, 99A UXBRIDGE ROAD
This will be the case for
RICKMANSWORTH Postcode WD3 7DJ or from / / 2024 to / / 2024 Mobile 31 05 07 06 Date of birth 20 / 07 / 2000 I will/will not need to assess your fitness for work again at the end of this period. ================================ (Please delete as applicable) NI number Issuer’s name RAMANESWARAN, Difijah (Dr) What you need to do now Issuer’s profession Doctor • If you are employed: Please show this form to your employer. You could get Statutory Sick Pay (SSP) which is paid by your employer. If your employer cannot pay you SSP Date of statement 31 / 05 / 2024 they will give you form SSP1 to claim benefits. Issuer’s address • If you are self-employed: You could claim benefits. THE COLNE PRACTICE • If you are already claiming benefits: Please send this form to the office dealing with Colne House Surgery, 99A Uxbridge Road your claim. Rickmansworth, WD3 7DJ Telephone: 01923776295 • If you need to make a claim to benefits: Visit www.gov.uk/browse/benefits or phone 0800 328 5644 (8am to 6pm Monday to Friday). Textphone users call 0800 328 1344. Unique ID: Med 3 04/22 EA1C3DD7-F73B-43DE-8D1B-ADDB2D8194B9
