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

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, Mrs, Miss, Ms Gabriel Alin Cuvinciuc Help getting back to work if you are employed
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If you’ve been off work or are likely to be off work sick for 4 weeks or more,
I assessed your case on: 31 / 03 / 2022
you may be able to have a free occupational health assessment. You will be able
and, because of the to discuss what advice and support you need to help you go back to work sooner.
Pain in upper arm
following condition(s): You can ask your GP or employer to refer you. For further information:
● in England and Wales visit www.fitforwork.org or phone 0800 032 6235
● in Scotland please visit www.fitforworkscotland.scot or phone 0800 019 2211.

What your doctor’s advice means

I advise you that: X you are not fit for work.
‘You are not fit for work’: Your health condition means that you may not be able
you may be fit for work taking account of to work for the period shown. You can go back to work as soon as you feel able to
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the following advice: and, with your employer's agreement, this may be before your fit note runs out.
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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
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phased return to work amended duties this happens your employer will treat this form as though you are ‘not fit for work’.
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altered hours workplace adaptations You don’t need to get another of these forms from your doctor.
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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.
sick note for 2 weeks
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
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CUVINCIUC
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Other names GABRIEL ALIN

Address FLAT 19 SANDWELL HOUSE, 48 FOREGATE STREET

This will be the case for

WORCESTER Postcode WR1 1EE
or from 31 / 03 / 2022 to 14 / 04 / 2022 Date of birth 18 / 11 / 1977 Mobile
I will/will not need to assess your fitness for work again at the end of this period.
================================ NI number
(Please delete as applicable)
Doctor’s signature What you need to do now
● 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
Date of statement 04 / 04 / 2022 pay you SSP they will give you form SSP1 to claim benefits.
● If you are self-employed: You could claim benefits.
Doctor’s address ● If you are already claiming benefits: Please send this form to the office dealing
Spring Gardens Group Medical Practice
Spring Gdns Group Med Practice, , Spring Gardens with your claim.
Worcester, WR1 2BS ● If you need to make a claim to benefits: Visit www.gov.uk/browse/benefits or
Telephone: 01905 744400 phone 0800 055 6688 (8am to 6pm Monday to Friday). Textphone users call
Unique ID: Med 3 01/17 AFD45153-9904-4A45-813B-BDEE04DB862E
0800 023 4888.