Self Referral To Occupational Health - Staff
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Self Referral To Occupational Health - Staff Occupational Health Department Lenton Hurst, University Park Nottingham, NG7 2QL Tel: (0115) 951 4329 Fax: (0115) 951 4328 Email: BR-Occ-Health@nottingham.ac.uk Completed forms should be sent to The University of Nottingham Occupational Health Department, Lenton Hurst, University Park, Nottingham NG7 2QL. 1. Employee Details (Employee to complete) Your Name:.................................................................Mr/Mrs/Ms/Dr:.................... (BLOCK CAPITALS) Job title:.......................................................................Faculty:........................................................ School/Dept:..........................................................Division (if applicable):....................................... Location/Site at Work:.......................................................Manager’s Name:.................................. Date of Birth:.........................................Payroll No:......................................................................... Work Tel No:.................................................................................................................................... E-mail address:................................................................................................................................ Home address:................................................................................................................................. ......................................................................................................................................................... Home Tel No:................................................Mobile Tel No:............................................................ I, the above, wish to be considered for a self referral to The University of Nottingham Occupational Health Department I understand that I can only make a referral on the basis of any concerns I may have relating to the effect my health has on my job or concerns relating to the effect of my job on my health. I understand that Occupational Health may consider that my employer should be given advice relating to my health at work following this referral. I understand that failure to attend an Occupational Health appointment with no notice may result in a charge equivalent to the cost of the appointment. Acceptance of an appointment will be regarded as authorisation to deduct this charge from salary. Document1 Page 1 of 4 Document1 2. Referral Details (Employee to complete) My reason for requesting this referral is as follows: .................................................................................................................................................................. .................................................................................................................................................................. .................................................................................................................................................................. .................................................................................................................................................................. .................................................................................................................................................................. .................................................................................................................................................................. Please describe your job in as much detail as possible including weights lifted and repetitions required: (Please attach a job description if available) .................................................................................................................................................................. .................................................................................................................................................................. Amount of sick leave taken in past year (attach copies of any sick notes or other relevant information): .................................................................................................................................................................. .................................................................................................................................................................. If there are any dates where you would not be available to attend Occupational Health, please give details below: .................................................................................................................................................................. .................................................................................................................................................................. Please provide any additional information here: .................................................................................................................................................................. .................................................................................................................................................................. .................................................................................................................................................................. ................................................................................................................................................................. .................................................................................................................................................................. Signed:…………………………………….…Name:....................................................Date:....................... Referred Employee Document1 Page 2 of 4 Document1 SELF REFERRAL TO OH CONSENT FORM A medical report written by an Occupational Health Adviser for The University of Nottingham will on the request of an employer adheres to the principles outlined in the Access to Medical Reports Act (1988). For further information please read page two of this form. Employee’s Name:.................................................................................................................... Date of Birth:.............................................Payroll No:............................................................... GP Name address and contact details: ................................................................................... .................................................................................................................................................. .................................................................................................................................................. Specialist Name address and contact details: ......................................................................... .................................................................................................................................................. I, the above consent to the to the Occupational Health Department releasing details of the outcome of my medical assessment/health assessment by the Company Medical Officer/Occupational Health Advisor in confidence to my Employer. I understand that the report will not contain any detailed medical information and will advise only of my fitness to work, and of any adjustments, accommodations or restrictions that may be required. I understand that this report will only be used by Occupational Health to give guidance to my employer about my fitness for work. Relating to the Occupational Health report sent to my employer please indicate by selecting the ‘X’ via the ‘Click’ drop down function against one of the following options: I do not wish to have a copy of the report from Occupational Health to my Employer. I do wish to have a copy of the report from Occupational Health to my Employer sent at the same time as to my Employer. I do wish to have a copy of the report from Occupational Health to my Employer sent 2 days before it is sent to my Employer. Signature:..................................................Name (Print)............................................Date:................... Referred Employee Document1 Page 3 of 4 ACCESS TO MEDICAL REPORTS ACT 1988 This is a summary of your principal rights under the above Act, which is concerned with reports provided for employment or insurance purposes by a medical practitioner who is, or has been, responsible for your clinical care. The Act came into force on 1 January 1989, and can therefore, not be retrospectively applied to medical reports supplied before that date. OPTION A You may withhold your consent to prevent your employer, making an application for a report from a medical practitioner/OHA regarding your medical condition. OPTION B You may consent to the application, but indicate your wish to see the report before it is supplied. (You must make the necessary arrangements with the medical practitioner to see the report: it will not be sent to you automatically). The medical practitioner will be informed that you wish to have access to the report and will allow 21 days for you to see and approve it before it is supplied to the applicant. If the medical practitioner has not hear from you regarding arrangements to receive access to the report within 21 days of the application for the report, he/she will assume that you do not wish to see the report and that you consent to it being supplied. If you request a copy of the report, the practitioner may charge a reasonable fee to cover the cost of supplying it. When you see the report, if there is anything in it, which you consider incorrect or misleading, you can request (but this request must be in writing) that the medical practitioner amend the report, but he/she is not obliged to do so. If the medical practitioner refuses to amend it you may (i) (ii) (iii) withdraw consent for the report to be issued ask the medical practitioner to attach to the report a statement setting out your own views agree to the report being issued unchanged NOTE The medical practitioner is not obliged to show you any part of the report which he/she believes might cause serious harm to your physical or mental health or that of others, or which would reveal information about a third part or the identity of a third party who has supplied the practitioner with information about your health, unless the third part also consents. In those circumstances, the medical practitioner will so inform you and your access to the report will be appropriately limited. OPTION C You may consent to the application for the report but indicate that you do not wish to see the report before it is supplied. Should you change your mind after the application is made and notify the OHA / medical practitioner in writing, they allow 21 days to elapse after such notification so that you may arrange to have access to the report (if the report has not already been supplied before you change your mind). NOTE Whether or not you decided to seek access to the report before it is supplied, you have the right to seek access to it from the medical practitioner at any time up to 6 months after it was supplied. Document1 Page 4 of 4
