SSP1

Statutory Sick Pay and an

employee’s claim for benefit

If you are an employer

You must fill in this form when an employee

cannot get Statutory Sick Pay (SSP), or when

an employee’s SSP has come or is coming to

anend.

The information you give will help the

Department for Work and Pensions to decide

on an employee’s benefit application.

Please complete Parts A, B and C of this form.

If you are an employee

Your employer has given you this form because

you cannot get SSP, or because your SSP is

coming to an end.

You can find out the reasons why in Part C and

what to do next in Part D.

Part A

(Employer to complete)

When you have completed this form, you

must give it to the employee.

For more information about SSP go to

www.gov.uk/employers-sick-pay

Or you can contact HM Revenue and Customs

Employer helpline on 0300 200 3200.

Medical information

Please send this form to your employee with

any medical information they have given you

which covers a period you cannot pay SSP for.

You can ask your employee to give you medical

information as proof they cannot return to

work if they are off for more than seven days.

Medical information can be a Statement

of Fitness for Work, commonly known as a

fit note (sometimes known as sick notes or

doctor’s notes). A GP or hospital doctor can

issue a fit note.

Alternatively, you can use an Allied Health

Professional (AHP) report if you, the employer,

agree. A physiotherapist, podiatrist or

occupational therapist can issue an AHP report.

This medical information should state whether

or not the employee is not fit for work or may

be fit for work. Return medical information to

your employee as they may need it for future

benefit applications.

Please tick one of the following boxes

I have enclosed medical information that

covers a period I cannot pay SSP

I have not enclosed medical information

09/22 1 of 5 SSP1

We have many ways we can communicate with you

If you would like braille, British Sign Language, email, a hearing loop,

translations, large print, audio or something else please call us on

0800 169 0310 or textphone 0800 169 0314 and tell us which

you need.

Calls to 0800 numbers are free from landlines and mobiles.

Treating people fairly

We are committed to the Equality Act 2010 and treating people fairly.

To find out more about this law, search ‘Equality’ on www.gov.uk

I declare that the information I have given on this form is correct and complete

as far as I know and believe.

I understand that if this employee has been getting SSP, I must continue to

pay SSP up to and including the day before the date I have written in Part B of

thisform.

Employer’s name

Employer’s signature

Date

DD/MM/YYYY

Position in firm

Phone number

Fax number

Email address

Employer’s address

Postcode

Employer’s stamp

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Part A: If you are an employer

3 of 5 SSP1

Title

For example Mr, Mrs, Miss, Ms or other

Surname or family name

All other names, in full

Address

Postcode

National Insurance (NI) number

Clock, payroll or employee number

Tax reference number

This is also known as the Employee PAYE

reference.

Have you been paying your

employeeSSP?

Yes

Please tell us the start and end

datesof the payment.

Date DD/MM/YYYY

From

If payment has not ended yet,

pleasetell us the date when it will

end.

Date DD/MM/YYYY

(Employer to complete)

Part B: About your employee

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You cannot get SSP on or after

DD/MM/YYYY

This is because:

You got Employment and Support

Allowance during the last 12 weeks.

Your contract of employment has ended

or will be coming to an end.

You became sick after your contract of

employment ended.

(Note for employee: Your employer will

have to pay you SSP if they ended your

contract solely or mainly to avoid paying

SSP).

You will soon have been getting SSP for 28

weeks in a row.

Or, you have had SSP for 28 weeks in total,

made up of separate times you were sick

that were 8 weeks or lessapart.

Your average earnings for the 8weeks

before you were sick were less than the

Lower Earnings Limit.

You can find out more by searching for

rates and thresholds for employers on

www.gov.uk

You are expecting a baby soon or you

have just had a baby.

Note for employee:

• if you can get Statutory Maternity Pay

(SMP), which is money paid by the

employer to women for time off work

to have their baby, you cannot get

SSP during your 39 week maternity

payperiod

• if you cannot get SMP you may be able to

get a benefit payment called Maternity

Allowance (MA). If you can get MA, you

cannot get SSP.

You have been sick on and off for more

than 3 years. Each time you were sick, it

was for longer than 4days and you did

not go back to work for more than 8 weeks

before you were sick again.

You were away from work because of a

trade dispute which started before the

first day you were sick.

Note for employee:

• you may get SSP if you were already

getting it when the dispute began

• you may get SSP if you can show you

were sick and had no direct involvement

in the dispute – for example this could be

a strike, a walkout or a lockout.

You were sick while in legal custody. Or

you are now in legal custody or have been

given a prison sentence.

You were working outside the UK on

the day you first became sick and your

employer did not have to pay employer’s

class 1 National Insurance contributions

on your earnings on that day.

You have not started working for your

employer yet.

You did not tell your employer about your

sickness.

Part C: Why you cannot get Statutory Sick Pay

(Employer to complete)

If you disagree with your employer’s

decisionnot to pay you SSP, ask your

employerto explain it to you. If, after

talkingtoyour employer, you are still

unsureabout this decision you can visit

www.gov.uk/statutory-sick-pay for

moreinformation.

Ask your employer for a reason if you think:

• their decision not to pay you SSP is wrong

• you are not getting the right amount of SSP.

If you still disagree, you can phone HM Revenue

& Customs Statutory Payments Dispute team

on 0300 056 0630 for advice.

If you are still off work because of an illness

or disability you may be able to get money

andsupport:

• to help you get back to work, or

• if you are not able to work in the long term.

You may be able to apply for Universal Credit or

get help with housing costs. Your employer will

return any medical information they have to

you for future benefit applications.

If you have paid enough National Insurance

contributions, usually in the last 2 full tax years

you may be able to apply for:

• New Style Jobseeker’s Allowance

• New Style Employment and

SupportAllowance.

Please visit www.gov.uk/browse/benefits to

find out more.

You could ask your family, or someone you

know, if you can use their internet access.

Youcan also get access to the internet in your

local jobcentre.

If you need more information on what benefits

you might be able to apply for, local welfare

advice services, such as Citizens Advice, may

be able to help you.

Please note, this form is not an application

forbenefit.

Further help and support

If you cannot apply for benefit online or you

need further support you can:

For Universal Credit call:

• telephone: 0800 328 5644

• text phone: 0800 328 1344

• NGT text relay (if you cannot hear or speak on

the phone): 18001 then 0800 328 5644

• Welsh language: 0800 328 1744.

Monday to Friday, 8am to 6pm.

For New Style Jobseeker’s Allowance call:

• telephone: 0800 055 6688

• text phone: 0800 023 4888

• NGT text relay (if you cannot hear or speak on

the phone): 18001 then 0800 055 6688

• Welsh language: 0800 012 1888.

Monday to Friday, 8am to 5pm.

For New Style Employment and Support

Allowance call:

• telephone: 0800 055 6688

• text phone: 0800 328 1344

• NGT text relay (if you cannot hear or speak on

the phone): 18001 then 0800 055 6688

• Welsh language: 0800 328 1744.

Monday to Friday, 8am to 5pm.

How DWP collects and uses information

When we collect information about you

we may use it for any of our purposes.

Theseinclude:

• social security benefits and allowances

• child maintenance

• employment and training

• investigating and prosecuting tax

creditsoffences

• private pensions policy and

• retirement planning.

We may get information about you from

other parties for any of our purposes as the

law allows to check the information you

provide and improve our services. We may give

information about you to other organisations

as the law allows, for example to protect

against crime.

To find out more about our purposes, how we

use personal information for those purposes

and your information rights, including how to

request a copy of your information, pleasevisit

www.gov.uk/dwp/personal-information-charter

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Part D: Employee - what to do now