{{company_name}}
{{company_address}}
Phone: {{phone}} | Email: {{email}} | Web: {{website}}
Employee Details
| Field | Detail |
|---|---|
| Name | {{employee_name}} |
| Employee ID | {{employee_id}} |
| Department | {{department}} |
| Position | {{position}} |
| Manager | {{manager_name}} |
Leave Period
| Field | Detail |
|---|---|
| First day of absence | {{start_date}} |
| Expected return date | {{return_date}} |
| Total working days | {{days}} |
| Nature of illness (optional) | {{illness}} |
Medical Certificate
A medical certificate from a registered medical practitioner is required for any absence exceeding two (2) consecutive working days, or for absences immediately before or after a public holiday or weekend.
Declaration
I declare that the information provided is true and that I am unable to perform my duties for the period stated. I consent to {{company_name}} contacting the medical practitioner if verification is required.
Acknowledgement & Signatures
By signing below, both parties confirm they have read, understood, and agreed to the terms of this document.
Scope
Applies to all employees, contractors, and visitors of {{company_name}} while at Company premises or engaged in Company business.
Definitions
- "Occupational Health" means health risks arising from or related to work.
- "Reasonable Accommodation" means any modification to enable performance of essential duties.
- "Health Information" means medical, fitness-for-work, and related personal data.
Roles & Responsibilities
| Role | Responsibility |
|---|---|
| Executive Sponsor | Owns occupational health strategy and resourcing. |
| HR / Health Officer | Coordinates assessments, accommodations, and record keeping. |
| Line Manager | Identifies risks, supports return-to-work, escalates concerns. |
| Employee | Discloses fitness-for-work matters, follows medical advice, uses PPE. |
Risk Categories & Controls
| Risk | Mitigation | Owner |
|---|---|---|
| Workstation ergonomics | DSE assessment and adjustments | HR / Facilities |
| Mental health / burnout | EAP, workload reviews, manager training | HR |
| Infectious disease | Hygiene controls, isolation guidance | Health Officer |
| Physical hazards | PPE, training, incident reporting | Operations |
Fitness for Work & Accommodations
- Employees with a medical condition affecting work shall notify HR in confidence.
- An occupational health assessment may be arranged at Company cost where required.
- Reasonable accommodations are agreed in writing with the employee and manager.
- Confidential medical records are stored separately from personnel files.
Incident & Injury Reporting
Confidentiality of Health Data
Health information is processed only on a legitimate basis under applicable data protection law. Access is restricted to authorized health and HR personnel, and disclosure to managers is limited to fitness-for-work conclusions.
Document Control
| Field | Value |
|---|---|
| Document Owner | Human Resources — {{company_name}} |
| Category | Health & Medical |
| Version | 1.0 |
| Effective Date | {{date}} |
| Next Review | Annually from effective date |
| Approved By | {{manager_name}} |
| Classification | Internal — Confidential |
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