Form of certificate of incapacity for work: where to get a sample

Legislative regulation

If a citizen was absent from work due to health reasons, then in order to receive benefits he must issue a sick leave certificate. No other type of document gives this right. The employee can submit it to the employer’s accounting department within six months after recovery.

The document must be signed by a doctor. The sheet should be provided in the form approved by the order of the Ministry of Health and Social Development dated April 26. 2011 No. 347.

You can check whether the sick leave is real or not in the register on the website of the Federal Social Insurance Fund of the Russian Federation.

Art. 59 Federal Law dated November 21, 2011 contains information that you can obtain a certificate of incapacity for work for a period of illness, if injury or poisoning is diagnosed, during treatment in a sanatorium, when caring for a family member, due to quarantine, during pregnancy and childbirth, and when other circumstances affecting the citizen’s performance.

The number of days of sick leave may vary depending on the severity of the person’s condition.

From 2021, an electronic form is available.

The procedure for filling out sick leave by an employer

The employer is responsible for paying benefits. He can make corrections in his part of the form. Information entered by a medical institution cannot be corrected. If a mistake is made by a health worker, the certificate of incapacity for work is returned for replacement (paragraph 5, clause 56 of the Procedure for issuing certificates of incapacity for work). Otherwise, the sick leave will not be accepted by the social insurance authorities and the employee will not receive disability benefits.

First of all, you should check the period of incapacity indicated on the sheet:

When filling out sick leave, the employer also follows the established rules. They are spelled out in the following legal acts:

• Letter of the Federal Social Insurance Fund of the Russian Federation dated September 14, 2011 N 14-03-11/15-8605 On the issue of issuing sick leave forms of the new sample;
• Letter of the Federal Social Insurance Fund of the Russian Federation dated October 28, 2011 N 14-03-18/15-12956 (as amended on December 23, 2011) On clarification of certain provisions of the Procedure for issuing certificates of incapacity for work, approved by Order of the Ministry of Health and Social Development of the Russian Federation dated June 29, 2011 N 624n;
• Letter of the Federal Social Insurance Fund of the Russian Federation dated December 23, 2011 N 14-03-11/15-16055 On clarification of certain issues that arise when issuing certificates of incapacity for work.

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Order of the Ministry of Health and Social Development of the Russian Federation dated June 29, 2011 n 624n

Filling out sick leave by the organization where the employee works is carried out as follows:

Along with the certificate of incapacity for work, the chief accountant submits to the Social Insurance Fund an extract from the accounting department, which reflects all the information necessary for calculating benefits. The extract must contain data on the employee’s length of service, his average monthly and average daily earnings, salary and allowances, and work report card.

If a fixed-term employment contract is concluded between an employee and an organization, the duration of which does not exceed 6 months, a special mark is affixed - 46. In this case, benefits are paid for no more than 75 days of such a contract.

If an accountant made an error in calculations and noticed it himself, then he has the right to make corrections. Provided that there are no more than two of these corrections for the entire document.

What to pay attention to

The employer fills out the certificate of incapacity for work in the same way as in the case of doctors - with a black non-ballpoint pen or in a machine version.
It is allowed to fill out one part of the sick leave manually, and the other by machine. So, if the employer does not have a special program for entering data into the form, then he can fill it out by hand. Even if the medical institution filled out its part using a PC. The employer has the right to independently make corrections to the form if it discovers errors before submitting the document to the Social Insurance Fund. However, special rules apply to changes made. If they are violated, the Social Insurance Fund has the right to refuse to pay temporary disability benefits to an employee of the organization.

The employer is required to complete the document within 10 working days after receiving it from the employee. At the same time, the legislation does not oblige the transfer of a certificate of temporary loss of ability to work to the Social Insurance Fund.

If an organization pays sick leave for an employee on its own, then this remains its right. At the same time, she has the right to submit the completed document form to the Social Insurance Fund to receive compensation against her budget.

What are the main elements of a certificate of incapacity for work?

The form of certificate of incapacity for work is a document in A4 format. The doctor enters all entries in yellow fields located on a blue background. The reverse side of the sheet is also made in blue. No entries are made on it, but there is information about filling rules and codes. The document contains the main elements in the form:

1. Protection against falsification. Sick leave certificates comply with anti-counterfeit standards. In the upper right corner there is a code with a 12-digit combination. If you carefully examine the form, you can see on it the emblem of the Social Insurance Fund of the Russian Federation.
2. Matrix code. It is located on the front side in the upper left corner and is used for automatic processing. It encodes the reason for the disability, violation of the regime, if any, and other personal information. This element is designed to completely eliminate the possibility of counterfeiting.

The form was developed in such a way that it was easy to fill out. To do this, a reminder was placed on the reverse side. It helps to avoid shortcomings that could lead to the FSS refusing to pay benefits.

When filling out, representatives of a medical institution must follow the following rules:

1. The required data is entered in the appropriate columns in block letters.
2. Information about the name, address and OGRN must be present. This data will allow you to identify the institution that issued the leaflet.
3. The reason for absence from work is indicated in the document in the form of a special code.
4. If a woman is registered in the early stages of pregnancy, the doctor makes a note in the appropriate box, which will allow her to receive a one-time benefit based on sick leave in the future.
5. In the cells, the doctor indicates his position, the name of the medical organization, and his place of work - the name of the organization. He must place the data in the allotted number of cells. If the information does not fit, it is allowed to shorten it, but so that it is clear.
6. At the end, stamps of the medical institution are placed, which should not appear on the information cells. It is important that the seal imprint contains the same name of the organization as that indicated on the sheet. Then the sheet will be valid.

If the doctor manages to spoil the form while filling it out, a new sheet is issued in its place.

If the employer made a mistake, then a new form will not be issued; it will have to be corrected according to the established rules. The form of a certificate of incapacity for work contains the following information from the employer:

1. The name of the organization without quotation marks, problems between words - one empty cell.
2. Type of employment: main or part-time.
3. Registration code in the Social Insurance Fund and subordination code. It is assigned to the company at the time of registration.
4. TIN and SNILS of the employee. If the TIN is not issued, then the field is left blank.
5. Conditions for calculating benefits. If the calculation of payments differs from the generally accepted norm, then for each situation there is a code from 43 to 51. They are listed on the back of the form.
6. Injury sustained at work. If this is the cause of disability, then it is necessary to indicate the date when the N-1 act was issued. If there was no injury, leave this column blank.
7. Start date of work. It is filled out if the employee violates the deadline for returning to work. This violation gives the right to cancel the employment contract.
8. Insurance experience. The period during which the employee was insured and the employer paid contributions for him is indicated.
9. Benefit calculation period. This is the start and end date of sick leave.
10. Average earnings. It is determined for two calendar years preceding the disease.
11. Wages per day. To do this, the amount of average earnings is divided by the number of days worked.
12. Benefit amount. The employer pays for the first 3 days of illness, the rest - the Social Insurance Fund. The calculations take into account the experience coefficient.
13. Responsible persons. When the filling is completed, the form is signed by the employer and the chief accountant.

Approval of a document is possible only if it is filled out correctly, but it is not always possible to avoid errors, omissions and inaccuracies. If shortcomings are made, they can be corrected, but correctors cannot be used. The error should be crossed out with a neat, thin line, and the correct information should be indicated on the back of the form. Corrections must be certified using the name, position and signature of the manager. If the organization has a round seal, it must be placed next to the signature.

If the head of the company issued an order to fill out the sheet to the personnel officer or accountant, he will still bear responsibility.

Fewer and fewer people fill out the form in paper form. Many people prefer the electronic form of the document. This is convenient, especially if the employee gets sick on a business trip or is being treated in another city. Information about electronic certificates of incapacity for work is entered into the register, for which the Social Insurance Fund has developed a special program. For the employer, the data will be available at any time of the day after logging into your personal account. The register displays all information about the employees of a particular company.

To gain access to the system, it is enough to own minimal computer equipment. If the employer does not have it, then the sheet can be printed.

Form and sample of certificate of incapacity for work [2019]

Form and sample of certificate of incapacity for work (sick leave) 2016.

The procedure for issuing a certificate of incapacity for work

The procedure for issuing a certificate of incapacity for work. Violations in the preparation of certificates of incapacity for work. By order of the Ministry of Health of the Russian Federation dated April 26, 2011. No. 347n “On approval of the form of a certificate of incapacity for work”, from July 1, 2011, a new form of a certificate of incapacity for work is being introduced on the territory of the Russian Federation, confirming the fact of temporary disability. The form of certificate of incapacity for work (hereinafter referred to as LN) is made on special paper, with an increased degree of protection, which is supplemented with watermarks in the form of the FSS of Russia logo, form size 210X297 (A4); -color: front side - blue background, light fields for filling - yellow, back side - blue. In the upper right corner of the LN form, as well as its spine, there is a bar code, which is a twelve-digit identification number of the form. The main difference between the new LN form and the old one is that now it can be filled out electronically, and all entries must be made in specially designated cells. The new format involves automatic processing of a machine-readable certificate of incapacity for work. For this purpose, a binary code is used (on the front side in the upper left corner), in which all the information entered into the LN will be encoded. The Social Insurance Fund of the Russian Federation has developed a program for medical institutions that allows you to enter data into LN. The program allows you to type a two-dimensional matrix code containing LN data. On the reverse side of the form there is information on filling out a certificate of incapacity for work indicating the necessary codes. The procedure for issuing LN was approved by order of the Ministry of Health and Social Development of Russia dated June 29, 2011. No. 624n.

Basic requirements for drawing up a certificate of incapacity for work: Entries on the certificate of incapacity for work are made in Russian in printed capital letters in black ink or using printing devices. You can use a gel, capillary or fountain pen. The use of a ballpoint pen is not allowed. Entries on the certificate of incapacity for work should not go beyond the boundaries of the cells provided for making the corresponding entries, and also should not come into contact with the boundaries of the cells. All entries in specially designated cells are entered starting from the first cell. In accordance with the clarifications of the Social Insurance Fund of the Russian Federation dated October 28, 2011. No. 14-03-18/15-12956 it is permissible to fill out a certificate of incapacity for work either using printing devices or filling it out in block letters manually. The seals of a medical organization or medical and social examination institution may protrude beyond the designated area, but should not fall into the cells of the information field of the certificate of incapacity form. The seal of a medical organization must correspond to the name specified in the charter of the medical organization. When issuing certificates of incapacity for work in some medical organizations (psychiatric, drug treatment organizations, centers for the prevention and control of AIDS and infectious diseases, etc.), special seals or stamps may be used without indicating the organization’s profile.

Registration of a certificate of incapacity for work: In the line “primary”, the corresponding o is made in the event that the certificate of incapacity for work is primary. In the line “duplicate” is entered in the case when, due to the loss of a certificate of incapacity for work, a duplicate certificate of incapacity for work is issued to the insured person by the attending physician and the chairman of the medical commission. Violation: when formatting the “duplicate” line, the “primary” or “continuation” lines are not formatted. In the line “continuation of certificate of incapacity for work No...” the number of the previous certificate of incapacity for work is indicated if the issued certificate of incapacity for work is a continuation of a previously issued certificate. The line “(name of the medical institution/full name of the private practicing doctor)” indicates the full or abbreviated name of the medical institution, the surname and initials of the doctor engaged in private medical practice, who provided medical care, and issued a certificate of incapacity for work. The line “(address of the medical institution/private practitioner)” indicates the address of the medical institution or the address of the provision of medical services by a doctor engaged in private medical practice (name of urban or rural settlement, street, number of house, building, apartment), corresponding to the addresses of the actual issuance of certificates of incapacity for work and carrying out medical activities in accordance with the license of a medical organization or private practitioner. The specified data is entered at intervals of one cell, the building number is indicated through a “/” sign in the cell after the house number, the apartment number is indicated through a space in one cell after the house or building number (for example, |B|a|r|n|a |у|л||С|у|х|о|в|а| ||5|/|3||13|)". The line “Date of issue” indicates the day, month and year of issue of the certificate of incapacity for work. The date of issue of the medical document must correspond to the date of issue of the medical document upon discharge from the hospital. The date of issuance of the personal information must correspond to the date of the patient’s first visit to the doctor, with the exception of: - issuance of the personal information in the past by the decision of the medical commission; - when issuing a duplicate LN.

The line “(OGRN/OGRNIP)” indicates the main state registration number in accordance with the document confirming the state registration of the medical organization that issued the certificate of incapacity for work, or the main state registration number of an individual entrepreneur - a private practitioner who issued the certificate of incapacity for work, affixed in accordance with the Certificate on state registration of an individual as an individual entrepreneur. In the “Full Name” line, the surname, first name and patronymic (patronymic name is indicated if available) of the temporarily disabled citizen are indicated in the appropriate cells in accordance with the identity document with a space of one cell between the surname and initials. The line “Date of Birth” indicates the date of birth of the disabled citizen. In cells “m” “f” the corresponding o is entered. In the line “Cause of disability”: in the “code” cells the corresponding two-digit code is indicated in the “additional code” cells an additional three-digit code is indicated In the line “(surname, initials of the doctor)” the surname of the medical worker who issued the certificate of incapacity and his initials (with a space) are indicated in one cell). In the line “place of work - name of organization” the full or abbreviated name of the organization, or the surname and initials of the employer - an individual (with an interval of one cell) is indicated. In the “main” line it is written about in the event that a certificate of incapacity for work was issued for presentation at the main place of work. In the line “part-time work No.” it is done if the certificate of incapacity for work was issued for presentation at the place of work on an external part-time basis and the number of the certificate of incapacity for work issued for presentation at the main place of work is indicated. In the “date 1” line, the date of change in the cause of disability, the expected date of birth, the start date of the voucher are entered - when sending tuberculosis patients on vouchers to specialized (anti-tuberculosis) sanatorium-resort institutions for treatment in the case when sanatorium treatment replaces inpatient treatment, as well as after-care after inpatient treatment, when a citizen is referred by a medical organization for treatment to a clinic of a research institution (institute) of balneology, physiotherapy and rehabilitation; when referred for follow-up treatment to specialized sanatorium-resort organizations (departments) immediately after inpatient treatment; when sending persons injured in connection with a serious accident at work to sanatorium-resort treatment during a period of temporary incapacity for work (hereinafter referred to as a voucher for treatment (follow-up treatment); In the line “date 2" the end date of the voucher for treatment (follow-up treatment) is entered. line "Voucher N" indicates the number of the voucher for treatment (follow-up treatment). In the line "OGRN of a sanatorium or clinic of a research institute" a sanatorium-resort institution, a clinic of a research institution (institute) of balneology, physiotherapy and rehabilitation indicates the main state registration number in accordance with the document , confirming the state registration of a medical organization. The line “for care” is filled in in the case of caring for a sick family member (including during the quarantine of a child): In the line “age (years/month)” in the first two cells the number of full years of the sick member is indicated the family being cared for, and in the case of caring for a sick child under the age of 1 year, the first two cells are not filled in, and the child’s age in months is indicated in the second two cells. In the line “family relationship” the corresponding two-digit code is indicated: 38 - mother; 39 - father; 40 - guardian; 41 - trustee; 42 - another relative who is actually caring for a sick family member. In the line “Name of the family member being cared for,” the surname, first name, patronymic (patronymic name is indicated if available) of the citizen being cared for (with spaces in one cell) is indicated. When caring for two children at the same time, in the first row of cells of the named line the age, relationship, surname, first name, patronymic of the first child being cared for is indicated, in the second row of cells of the said line the mentioned data for the second child being cared for is indicated. When caring for more than two children at the same time, when a second certificate of incapacity is issued, in the first and second row of cells of the named lines the age, relationship, surname, name, patronymic of other children being cared for are indicated, the remaining lines (columns) of the certificate of incapacity are drawn up identical to the lines (columns) of the first certificate of incapacity for work. In the line “Registered in the early stages of pregnancy (up to 12 weeks)” in the “yes” and “no” cells, this is done if the relevant information is available.

In the line “Notes on violation of the regime”, depending on the type of violation, the following two-digit code is indicated: 23 - non-compliance with the prescribed regime, unauthorized leaving the hospital, leaving for treatment in another administrative region without the permission of the attending physician; 24 – late attendance at a doctor’s appointment; 25 - going to work without being discharged; 26 - refusal to refer to a medical and social examination institution; 27 - late appearance at the medical and social examination institution; 28 - other violations. The date of the violation is indicated in the “Date” line, and the signature of the attending physician is placed in the “Doctor’s signature” field. If there were no violations of the regime, the specified lines are not filled in. In the line “Stayed in hospital” in cells “From - to” the start and end dates of the citizen’s stay in an inpatient medical institution are entered, respectively; in the table “Exemption from work” of the certificate of incapacity for work, an entry is made about the continuation of treatment. In the case of long-term inpatient treatment and the need to submit a certificate of incapacity for payment, the corresponding terms of treatment are indicated in the table “Exemption from work” and the line “Stayed in hospital”; in the line “Other” the corresponding two-digit code is entered - “continues to be ill”. When discharged from a hospital, a disabled citizen is issued a new certificate of incapacity for work, which is a continuation of the previously issued one, while in the line “Was in hospital” the total duration of treatment is indicated, and in the table “Exemption from work” the terms of treatment minus the days indicated in the previously issued certificate of incapacity for work " When sent for a medical and social examination (MSE), the certificate of incapacity for work indicates the corresponding dates in the lines: “Date of referral to the ITU bureau”, “Date of registration of documents in the ITU bureau”, “Examined at the ITU bureau “Disability group established/changed” in Arabic numerals the disability group (1, 2, 3) is indicated if, as a result of examination at an ITU institution, the person’s disability group is established or changed. In the field “Signature of the head of the ITU bureau” the signature of the head of the ITU bureau is placed. When a disability group is established, the period of temporary disability ends on the date immediately preceding the day of registration of documents at the ITU institution. For temporarily disabled persons for whom disability has not been established, the certificate of incapacity for work can be extended by decision of the medical commission until the restoration of working capacity with the frequency of extending the certificate of incapacity for work by decision of the medical commission at least after 15 days or until re-referral to medical examination. If a disability group has been established, but the patient continues to be ill, a “primary” certificate of incapacity must be issued. In the line “Start work” in cells “from” the date of restoration of working capacity is indicated the next day after the examination and recognition of the citizen as able to work. In the line “Other” the following two-digit code is indicated: 31 - if the citizen continues to be ill and is issued a new certificate of incapacity for work (continued); 32 - when disability is established; 33 - when changing the disability group; 34 - in case of death; 35 - in case of refusal to conduct a medical and social examination; 36 - in the case when a citizen, after issuing or extending a certificate of incapacity for work, did not show up for an appointment, but at the next visit was recognized as able to work; 37 - in case of referral for follow-up treatment immediately after inpatient treatment. Following the two-digit code entered in the “Other” line, in cells for codes 32, 33, 34 and 36, the date of establishment, change of disability group, date of death of the citizen, date of appearance as able-bodied is also entered. In the line “Slip issued (continuation) N” the number of continuation of the certificate of incapacity for work is indicated. The signature of the attending physician is placed in the “Doctor’s signature” field. When closing the certificate of incapacity, the person who issued the certificate of incapacity for work carefully crosses out the empty lines of the table “Exemption from work” with one horizontal line. Violation. At the same time, the line “Get to work” is drawn up and the code “31” is entered in the line “Other”. If the code “31” is entered, the date is not entered. If there are errors in filling out a certificate of incapacity for work, it is considered damaged and a new certificate of incapacity for work is issued in its place. When issuing certificates of incapacity for work in the form approved by order of the Ministry of Health and Social Development of Russia dated April 26, 2011 No. 347, in the section “To be filled out by a doctor,” the following violations are allowed in medical organizations, which can be conditionally divided into 2 groups: 1. Violations in the preparation of certificates of incapacity for work that do not affect amount of benefits for temporary disability, pregnancy and childbirth (technical shortcomings in the preparation of the certificate of incapacity for work): - entries in the certificate of incapacity for work are not made in printed capital letters; - entries on the certificate of incapacity for work are made with a ballpoint pen; - entries on the certificate of incapacity for work go beyond the boundaries of the cells and (or come into contact with the boundaries of the cells); - entries in the lines: “name of the medical organization”, “address of the medical organization”, “place of work - name of the organization”, “full name of the family member being cared for”, “Last name and initials of the doctor” of the table “Exemption from work” are indicated without interval of one cell; - the name of the medical organization is indicated incorrectly; — the name of the employer is indicated incorrectly. By letter from the FSS dated September 30, 2011. N 14-03-11/15-11575 clarifies that the presence of technical deficiencies in the form filled out in handwriting is not a basis for the employer to demand re-issuance of the certificate of incapacity for work and refuse to assign and pay benefits, if all entries in the certificate of incapacity for work are read. 2. Violations in the preparation of certificates of incapacity for work that affect the amount of benefits for temporary disability, pregnancy and childbirth: - in the line “primary”, “duplicate”, “continuation of certificate of incapacity for work No.” the corresponding o is not indicated; — a note on the certificate of incapacity for work regarding violation of the regime prescribed by the doctor was not made; - the code in the line “Cause of disability” is incorrectly specified, etc. EXAMPLE: issuance of LN, code “02”, code “021” is not entered. “the additional code “021” in the line “Cause of disability”, as well as a two-digit code in the line “Notes on violation of the regime” must be indicated in each certificate of incapacity for work issued as a continuation of the initial certificate of incapacity for work.” - absence of the signature of the chairman of the VC on each line of the LN after the first 15 days of release from work; — after examination at the ITU and establishment of the disability group, a PL was issued (continued). (LN (primary) must be issued, since the case of temporary disability “ends on the date preceding the day of registration of documents at the ITU institution”). If violations of this type are detected, the employer must return the certificate of incapacity to the insured person in order to correct the errors by the healthcare institution that issued this certificate.

Features of protecting forms of certificates of incapacity for work

A temporary disability certificate, a sample of which contains a number of elements to protect against counterfeiting in the form of:

1. The first background non-rapport mesh made with paints that luminescent under the influence of ultraviolet radiation.
2. The second background non-rapport grid.
3. One-and-a-half elements printed using a stochastic raster.
4. Text made using black inactenic paint, which is invisible in infrared radiation.
5. Negative microtext “LOCK OF WORK CAPACITY LIST”.
6. Interlinear inscriptions in positive microtext.
7. Numbering printing using black ink with a magnetic feature.
8. A barcode representing the twelve-digit number of the form.
9. Background grid depicting the logo of the Social Insurance Fund of the Russian Federation.
10. Matrix code.

The temporary disability certificate form is printed on paper containing three types of protective fibers. On the left side of the spine there is a technological number, which is not a document number.

Where can I get the form?

Any organization that has a valid license for medical activities, which also includes services for the examination of temporary disability, can issue a certificate.

A citizen can count on receiving a document from:

• attending physician;
• paramedic and dentist, as well as other medical workers with secondary education, in accordance with the decision of the executive authorities of the constituent entities of the Russian Federation in the field of healthcare;
• attending physicians of clinics and research institutes of prosthetics and prosthetics.

A person working in an ambulance, blood transfusion, hospital emergency department, mud bath, or special medical organizations cannot issue and approve a certificate of incapacity for work. These include preventive medical centers and forensic bureaus.

A citizen can receive a document on the day of applying to the institution or at the time the sick leave closes. But, if the slip was issued to receive benefits in connection with pregnancy and childbirth, then it will be issued on the closing day.

If the patient is sent to another clinic, then the sheet is issued on the day of treatment, and he can extend or close it already in the institution where he was sent.

If treatment has been carried out for a long time, the medical organization issues a new certificate of incapacity for work, and the previous one is issued for payment of benefits.