{"id":9,"date":"2016-10-05T15:05:55","date_gmt":"2016-10-05T14:05:55","guid":{"rendered":"http:\/\/www.surgeryweb.org.uk\/newdemo\/?page_id=9"},"modified":"2026-11-01T14:24:45","modified_gmt":"2026-11-01T14:24:45","slug":"med3-fit-notes","status":"publish","type":"page","link":"https:\/\/surgeryweb-scot.org.uk\/55003\/med3-fit-notes\/","title":{"rendered":"Med3 Fit Notes"},"content":{"rendered":"<h3>If you\u2019ve been off sick for more than 7 days<\/h3>\n<p>To request a sick note:<\/p>\n<ul>\n<li>fill out a sick note request form below<\/li>\n<li>phone or visit the surgery from 9am to 5pm<\/li>\n<\/ul>\n<h3>If you\u2019ve been off sick for 7 days or less<\/h3>\n<p>If you\u2019re off work sick for 7 days or less, your employer should not ask for medical evidence that you\u2019ve been ill. Instead, they can ask you to confirm that you\u2019ve been ill. You can do this by filling in a form yourself when you return to work. We call this self-certification.<\/p>\n<p><a href=\"https:\/\/www.nhsinform.scot\/care-support-and-rights\/health-rights\/fit-notes\/getting-a-fit-note\/\" target=\"_blank\" rel=\"noopener noreferrer\" data-link-id=\"338026\" data-use-default-display=\"false\" data-use-default-title=\"false\" data-toggle=\"tooltip\" data-placement=\"bottom\" data-bs-original-title=\"Find out more about sick notes\">Find out more about sick notes<\/a> on the NHS Inform.<\/p>\n<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_22' style='display:none'><div id='gf_22' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Sick Note Request<\/h2>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_22' id='gform_22'  action='\/55003\/wp-json\/wp\/v2\/pages\/9#gf_22' data-formid='22' novalidate>\n        <div id='gf_progressbar_wrapper_22' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>2<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_50' style='width:50%;'><span>50%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_22_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_22' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fixed'><fieldset id=\"field_22_3\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"9165cd9f\" data-field-span=\"12\"><legend id='gfield_label_22_3' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Who are you completing this form for?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_22_3'>\n\t\t\t<div class='gchoice gchoice_22_3_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Yourself'  id='choice_22_3_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_22_3_0 gfield_label_22_3\"   \/>\n\t\t\t\t\t<label for='choice_22_3_0' id='label_22_3_0' class='gform-field-label gform-field-label--type-inline'>Yourself<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_22_3_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_3' type='radio' value='Someone else'  id='choice_22_3_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_22_3_1' id='label_22_3_1' class='gform-field-label gform-field-label--type-inline'>Someone else<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_22_12\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"334e6c67\" data-field-span=\"12\"><legend id='gfield_label_22_12' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>What is the patients name?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_22_12'>\n                            \n                            <span id='input_22_12_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_12.3' id='input_22_12_3' value=''   aria-required='true'     aria-labelledby=\"input_22_12_3_label gfield_label_22_12\"\/>\n                                                    <label for='input_22_12_3' id='input_22_12_3_label' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_22_12_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_12.6' id='input_22_12_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_22_12_6' id='input_22_12_6_label' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_22_13\" class=\"gfield gfield--type-date gfield--input-type-datedropdown gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"f0414d52\" data-field-span=\"12\"><legend id='gfield_label_22_13' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>What is the patients date of birth?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_22_13' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_22_13_2_container'><label for='input_22_13_2' id='input_22_13_2_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_13[]' id='input_22_13_2'   aria-required='true'   aria-labelledby=\"input_22_13_2_label gfield_label_22_13\" ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_22_13_1_container'><label for='input_22_13_1' id='input_22_13_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_13[]' id='input_22_13_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_22_13_3_container'><label for='input_22_13_3' id='input_22_13_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_13[]' id='input_22_13_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><fieldset id=\"field_22_14\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"0c0a2b3e\" data-field-span=\"12\"><legend id='gfield_label_22_14' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>What is the patients sex?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_22_14'>\n\t\t\t<div class='gchoice gchoice_22_14_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Male'  id='choice_22_14_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_22_14_0 gfield_label_22_14\"   \/>\n\t\t\t\t\t<label for='choice_22_14_0' id='label_22_14_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_22_14_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='Female'  id='choice_22_14_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_22_14_1' id='label_22_14_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_22_14_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_14' type='radio' value='gf_other_choice'  id='choice_22_14_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_22_14_2' id='label_22_14_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_22_14_other' class='gchoice_other_control' name='input_14_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_22_15\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"952f5ee0\" data-field-span=\"12\"><label id='gfield_label_22_15' class='gfield_label gform-field-label' for='input_22_15'><span class='gform-field-label__text'>What is the patients postcode?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_22_15' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_22_16\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"a43f68a5\" data-field-span=\"12\"><legend id='gfield_label_22_16' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>What is your relationship to the patient?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_22_16'>\n\t\t\t<div class='gchoice gchoice_22_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Parent'  id='choice_22_16_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_22_16_0 gfield_label_22_16\"   \/>\n\t\t\t\t\t<label for='choice_22_16_0' id='label_22_16_0' class='gform-field-label gform-field-label--type-inline'>Parent<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_22_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Guardian'  id='choice_22_16_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_22_16_1' id='label_22_16_1' class='gform-field-label gform-field-label--type-inline'>Guardian<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_22_16_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Spouse'  id='choice_22_16_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_22_16_2' id='label_22_16_2' class='gform-field-label gform-field-label--type-inline'>Spouse<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_22_16_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Carer'  id='choice_22_16_3' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_22_16_3' id='label_22_16_3' class='gform-field-label gform-field-label--type-inline'>Carer<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_22_16_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Son'  id='choice_22_16_4' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_22_16_4' id='label_22_16_4' class='gform-field-label gform-field-label--type-inline'>Son<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_22_16_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Daughter'  id='choice_22_16_5' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_22_16_5' id='label_22_16_5' class='gform-field-label gform-field-label--type-inline'>Daughter<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_22_16_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Sibling'  id='choice_22_16_6' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_22_16_6' id='label_22_16_6' class='gform-field-label gform-field-label--type-inline'>Sibling<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_22_16_7'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='gf_other_choice'  id='choice_22_16_7' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_22_16_7' id='label_22_16_7' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_22_16_other' class='gchoice_other_control' name='input_16_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_22_6\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"82e155df\" data-field-span=\"12\"><legend id='gfield_label_22_6' class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>What is your name?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_22_6'>\n                            \n                            <span id='input_22_6_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_6.3' id='input_22_6_3' value=''   aria-required='true'     aria-labelledby=\"input_22_6_3_label gfield_label_22_6\"\/>\n                                                    <label for='input_22_6_3' id='input_22_6_3_label' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_22_6_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_6.6' id='input_22_6_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_22_6_6' id='input_22_6_6_label' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_22_7\" class=\"gfield gfield--type-date gfield--input-type-datedropdown gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"f8ca9bec\" data-field-span=\"12\"><legend id='gfield_label_22_7' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>What is your date of birth?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_22_7' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_22_7_2_container'><label for='input_22_7_2' id='input_22_7_2_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_7[]' id='input_22_7_2'   aria-required='true'   aria-labelledby=\"input_22_7_2_label gfield_label_22_7\" ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_22_7_1_container'><label for='input_22_7_1' id='input_22_7_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_7[]' id='input_22_7_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_22_7_3_container'><label for='input_22_7_3' id='input_22_7_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_7[]' id='input_22_7_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><fieldset id=\"field_22_8\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\" data-group-id=\"670f6bbf\" data-field-span=\"12\"><legend id='gfield_label_22_8' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>What is your sex?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_22_8'>\n\t\t\t<div class='gchoice gchoice_22_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Male'  id='choice_22_8_0' onchange='gformToggleRadioOther( this )'  aria-labelledby=\"label_22_8_0 gfield_label_22_8\"   \/>\n\t\t\t\t\t<label for='choice_22_8_0' id='label_22_8_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_22_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Female'  id='choice_22_8_1' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_22_8_1' id='label_22_8_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_22_8_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='gf_other_choice'  id='choice_22_8_2' onchange='gformToggleRadioOther( this )'     \/>\n\t\t\t\t\t<label for='choice_22_8_2' id='label_22_8_2' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_22_8_other' class='gchoice_other_control' name='input_8_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_22_9\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"0e17ff93\" data-field-span=\"12\"><label id='gfield_label_22_9' class='gfield_label gform-field-label' for='input_22_9'><span class='gform-field-label__text'>What is your postcode?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_22_9' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_22_10\" class=\"gfield gfield--type-phone gfield--phone-format-international gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"862f5fc5\" data-field-span=\"12\"><label id='gfield_label_22_10' class='gfield_label gform-field-label' for='input_22_10'><span class='gform-field-label__text'>What is your phone number?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_10' id='input_22_10' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"    \/><\/div><\/div><div id=\"field_22_11\" class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"2a21a82f\" data-field-span=\"12\"><label id='gfield_label_22_11' class='gfield_label gform-field-label' for='input_22_11'><span class='gform-field-label__text'>What is your email address?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_11' id='input_22_11' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <button type='button' id='gform_next_button_22_17' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_22_2' class='gform_page' data-js='page-field-id-17' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_22_2' class='gform_fields top_label form_sublabel_below description_below validation_below' data-column-layout='fixed'><fieldset id=\"field_22_20\" class=\"gfield gfield--type-date gfield--input-type-datedropdown gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"7eff7144\" data-field-span=\"12\"><legend id='gfield_label_22_20' class='gfield_label gform-field-label' ><span class='gform-field-label__text'>First date you were not at work due to this illness<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_22_20' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_22_20_2_container'><label for='input_22_20_2' id='input_22_20_2_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Day<\/label><select name='input_20[]' id='input_22_20_2'   aria-required='true'   aria-labelledby=\"input_22_20_2_label gfield_label_22_20\" ><option value=''>Day<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_22_20_1_container'><label for='input_22_20_1' id='input_22_20_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Month<\/label><select name='input_20[]' id='input_22_20_1'   aria-required='true'  ><option value=''>Month<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_22_20_3_container'><label for='input_22_20_3' id='input_22_20_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Year<\/label><select name='input_20[]' id='input_22_20_3'   aria-required='true'  ><option value=''>Year<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><div id=\"field_22_21\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\" data-group-id=\"c0e5de31\" data-field-span=\"12\"><label id='gfield_label_22_21' class='gfield_label gform-field-label' for='input_22_21'><span class='gform-field-label__text'>Total number of days you were ill or state ongoing<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_22_21' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div 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