SSP Form – Fill Out and Use This PDF

Under About you, enter the Surname or family name, the First name(s) and the Title: enter MR, MRS, MISS, MS, or other title.

Enter the National Insurance number.

Enter the Date of birth as DD MM YYYY.

Enter the Clock or payroll number.

Under About your sickness, give brief details.

What date did your sickness begin? Enter DD MM YYYY.

What date did your sickness end? Enter DD MM YYYY. If you do not know, leave this blank.

The dates you put in these two boxes may be days you do not normally work.

If you are sick for more than seven days, your employer may ask you for a medical statement of fitness for work ‘fit note' from your doctor.

Enter the date you last worked before your sickness began as DD MM YYYY.

Enter the time you finished work on that date, in 24 hours.

Was your sickness caused by an accident at work or an industrial disease? No or Yes.

If you answered ‘Yes', you may be able to get Industrial Injuries Disablement Benefit.

If you want information about claiming this benefit, ask at any Jobcentre Plus office or go to www.dwp.gov.uk.

Sign in the Signature box, next to SIGN.

Enter the Date as DD MM YYYY.

Enter the Phone number.

Give your completed form to your employer, and keep a copy for your own information. It will help them to decide if you can get SSP.

If you can get SSP, your employer will pay you in the same way they usually pay your wages.

If you cannot get SSP, your employer must give you form SSP1 to tell you why. You can use form SSP1 to support a claim for Employment and Support Allowance.

If you disagree with your employer's decision and you have also looked at the further information on the HMRC website, you can ask HM Revenue & Customs for a decision about your entitlement. You must do this within six months of the first day that you are notified of your employer's decision. Phone the HM Revenue & Customs Disputes Team on 0191 225 5221.

If you do not have much money coming in while you are sick, you may be able to get a Social Security benefit.

Contact any Jobcentre Plus office or go to www.dwp.gov.uk. You can also phone the Benefit Enquiry Line for people with disabilities. The phone call is free. The number is 0800 882 200 or in Northern Ireland 0800 220 674.

If you have any problems with hearing or speaking and use a textphone, phone 0800 243 355.

If you do not have your own textphone system, they are available to use at the Citizens Advice Bureau and main libraries.

If you want to know more about SSP go to www.gov.uk. HMRC may charge penalties where a person, either fraudulently or negligently, gives incorrect information or makes a false statement or declaration for the purpose of claiming entitlement to Statutory Sick Pay.

You can get more information about other help while you are sick in leaflet DWP1026 Help if you're ill or disabled. You can get leaflet DWP1026 from any Jobcentre Plus office, most advice centres like the Citizens Advice Bureau, or any post office (except in Northern Ireland), or go to www.dwp.gov.uk.