Please enable JavaScript in your browser to complete this form.Organisation name *Employee NameFirstLastEmployee date of birthDD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Employee telephone numberEmployee email addressDate of commencement in rolePreference of assessment (phone/teams/face to face)Final decision to be made by OH clinicianJob roleLocationHours of work/working patternAny specific requirements needed to assist in this assessment (e.g interpreter, advocate) Job profileDescribe duties of the position or attach a copy of the job description. Give details of any special features of work e.g. operates machinery, handles chemicals) Job description Drag & Drop Files, Choose Files to Upload Health surveillance job risksExposure to bodily fluidsExposure to dustExtremes of temperaturesHazardous substancesLone workingNight workingShift workingWorking at heightsWorking more than 48 hours per weekWorking outsideOtherOther (please specify)Attendance at workPlease give details of the employee’s absence record for the previous 12 months To include dates and number of days absent as well as reason/s for absence.Additional informationReason for referral *Long-term sickness absenceRecurrent short-term sickness absenceIll-health retirement assessmentConcerns about work performancesPhysical health conditionInvestigation of workplace illness or injuryPossible substance misuseOccupational exposure hazards concernMental health issuesCase conference with individual or line manager or HRFollow-upAdvice on fitness to return to workOtherOther (please specify) Additional requirements (these will incur additional charges) Health surveillancePregnancy risk assessmentDisplay screen equipment assessmentPlease provide details of current health concernHow is this affecting their ability to work How long has the issue been present What remedial action have you taken? Are there any specific concerns about the employees performance? What specific questions would you like answered? *Is there a single underlying reason to account for numerous short term absences?Does the condition have any implications for work performance/attendance/job contentAre there any reasonable adjustments that will assist the employee to return to work?If still at work, are there any reasonable adjustments that we can consider to support the employee to remain in work?What are the likely timescales involved for a return to workWill a period of rehabilitation be required and if so, in what form i.e. reduced hours or modified duties?On return to work is there likely to be any residual disability which will prevent them from being able to carry out normal duties? How long is this likely to last?Will the employee ever be able to return to full dutiesIs this individual likely to be regarded as having a disability under the Equality Act?OtherOther (please specify)DeclarationName of manager requesting referral FirstLastContact details of manager requesting referral I confirm that the reason for the referral has been fully explained to the employee and they have received a copy of this completed formYesName of People Team completing referral FirstLastSubmit
