Occupational Health Department
Cripps Health Centre, University Park
Nottingham, NG7 2QW
Tel: (0115) 951 4329
Fax: (0115) 951 4328
Email: BR-Occ-Health@nottingham.ac.uk
Management Referral to
Occupational Health
Employee
READ THIS CAREFULLY BEFORE COMPLETING THIS FORM
This form is to be completed by the authorised referring manager unless otherwise indicated. Please complete this
form and return it directly to the University of Nottingham Occupational Health Department, Cripps Health Centre,
University Park, Nottingham NG7 2QW.
Contact Details: For completion by Referring Manager (the report will be addressed to this person)
Your Name .............................................................. Mr/Mrs/Ms/Miss/Dr ................... (BLOCK CAPITALS PLEASE)
Contact Tel No ......................................................... Faculty ............................................................................
School / Dept ........................................................... Division (if appropriate) ...................................................
E-mail address .....................................................................................................................................................
Address for us to reply to .....................................................................................................................................
Line Manager for referred employee....................................................Work number.........................................
Dept/School/Division.............................................................................Campus..................................................
If applicable, associated Human Resources officer (who will receive a copy of the report):
Name................................................................ Tel................................E-mail.................................................
Employee’s Name................................................................................................................................................
Date of Birth .............................. Payroll No ................................... NI Number .....................................................
Address of Employee...........................................................................................................................................
Tel No for Employee Home..........................Mobile No ....... ........................Work No........................................
Job title of Employee.....................................................Email............................................................................
Dept/School/Division.............................................................................Campus..................................................
Reason(s) for referral (Please tick the relevant boxes and detail fully on next page)
Long term sickness absence (at 6 weeks or expected to be continuous sickness)
Short term sickness (frequent or sporadic sickness -please attach details to referral)
Work related health issue (eg DSE concern, manual handling concerns, dermatitis etc)
Self Referral (where employee has concerns regarding health and work and where the manager
agrees that referral is appropriate)
Other (eg, ill health retirement, please specify)
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Detailed reasons for referral:
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
Description of employees’ role in as much detail as possible including where relevant:



Manual handling burden
Psychological factors
Hazards in role
(Please attach a job description and/or relevant risk assessment wherever possible)
..............................................................................................................................................................
..............................................................................................................................................................
Amount of sick leave taken in past year (please attach copies of any fit notes or other relevant
information)
..............................................................................................................................................................
What information does the referring manager require?
What is the nature of the condition
affecting the employee’s ability to work?
Is this an underlying health condition?
Where there is a medical condition, is this
likely to reoccur? If so, what can the University
do if it does?
If a return to work is not imminent, what
treatment or intervention might there be
on his/her behalf, which will change
his/her situation and when might this be
received?
Are there any adjustments to be made to allow
the employee to return to work or to remain in
work?
Is the duration and/or pattern of absence
reasonable in relation to the employees
condition?
Is the condition likely to be covered under the
Equality Act 2010 or any other relevant
legislation?
Should there be any restrictions placed on
the employee’s duties? If yes, please give
details including timeframes.
Is the condition due to work related matters? If
so, what are they, how are they impacting and
how can the organisation support the
resolution.
Is the employee capable on health
grounds of carrying out the duties of the
post for which they are employed?
If redeployment is medically recommended,
are there any medical restrictions on the
individual’s capability to be taken into account
in considering the scope for redeployment?
Is ill health retirement likely to be
supported?
Any other information you feel would be useful
to the University in managing this employee?
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Please specify any other information required:
…………………………………………………………………………………………………………..……
……………………………………………………………………………………………………………..…
……………………………………………………………………………………………………………….
Employee comments (to be completed by the employee)
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………….……
Please detail the employee’s availability (dates and times) for attending to see Occupational
Physician
……………………………………………………………………………………………………………..……
If you consider that an OH workplace assessment may assist this case, please tick this box.
□
Please provide any other additional information that may be of relevance
………………………………………………………………………………………………………….………
……………………………………………………………………………………………………………….…
…………………………………………………………………………………………………………….……
Signed ………………………….…….. Name……………………………………… Date……………
Referring Manager
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MANAGEMENT REFERRAL TO OH CONSENT FORM
A medical report written by an Occupational Health Adviser written on behalf of The University of Nottingham
Occupational Health Department 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…………Responsible Manager……………..………
Address of Employee……………………………………………………………………………….
Employee Contact Number … ……………………………………………………………………..
Job Title of Employee………………………………………………………………………………..
Site Location of Employee………………………………………………………………………….
GP Name address and contact details……………………………………………………………
…………………………………………………………………………………………………………
Specialist Name address and contact details……………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
I 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 consent to a medical report being supplied by my GP or Hospital Specialist in confidence to my employers
Company Medical Officer/Occupational Health Adviser.
I understand that this report will only be used by Occupational Health to give guidance to my employer about my
fitness for work.
If my GP or specialist provides a report I do*/do not* wish to have access to the medical report before it is
supplied to my employers Company Medical Officer/Occupational Health Advisor. I understand that I am entitled
to 21 days in which to read the report and apply in writing to my GP/Specialist for any changes to be made to
the report, otherwise the report will automatically be forwarded to the Company Medical Officer/Occupational
Health Advisor. *delete as appropriate
Relating to the Occupational Health report sent to my employer please indicate 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.
Signed…………………………………Name (print) ……………………………… Date……………….
Employee Name
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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 its 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.
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