Employee
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
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, Lenton Hurst, University Park,
Nottingham NG7 2QL.
Contact Details : For completion by Referring Manager (the report will be addressed to this person)
Your Name Click here to enter text.
Mr/Mrs/Ms/Miss/Dr Click here to enter text.
(BLOCK CAPITALS PLEASE)
Contact Tel No Click here to enter text.
................... Faculty Click here to enter text.
.......................................
School / Dept Click here to enter text.
..................... Division (if appropriate) Click here to enter text.
.............
E-mail address Click here to enter text.
................................................................................................................
Address for us to reply to Click here to enter text .
...............................................................................................
Line Manager for referred employee...
Click here to enter text.
..Work number...
Click here.
..
Dept/School/Division...
Click here to enter text.
..Campus... Click here to enter text.
...
If applicable, associated Human Resources officer (who will receive a copy of the report):
Name...
Click here to enter text.
. Tel... Click here to enter text.
.E-mail … Click here to enter text.
.
Employee’s Name… Click here to enter text.
.....Date of Birth … Click here to enter text.
………….........
Payroll No ..
Click here to enter text.
...................NI Number … Click here to enter text.
............................
Address of Employee … Click here to enter text.
Tel No for Employee Home … Click here to enter text.
.
Mobile No … Click here to enter text.
...................Work No...
Click here to enter text.
...............................
Job title of Employee… Click here to enter text.
..Email...
Click here to enter text.
..
Dept/School/Division...
Click here to enter text.
...Campus...
Click here to enter text.
.
(Please select the relevant boxes and detail fully on next page)
Click Long term sickness absence (at 6 weeks or expected to be continuous sickness)
Click Short term sickness (frequent or sporadic sickness -please attach details to referral)
Click Work related health issue (e.g. DSE concern, manual handling concerns, dermatitis etc)
Click Self Referral (where employee has concerns regarding health and work and where the manager agrees that referral is appropriate )
Click Other (e.g., ill health retirement, please specify)
Документ14-1 Jan 2013
Документ1
Page 1 of 5

Detailed reasons for referral:
Click here to enter text.
.........................................................................................................................
..............................................................................................................................................................
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)
Click here to enter text.
.........................................................................................................................
..............................................................................................................................................................
Amount of sick leave taken in past year (please attach copies of any fit notes or other relevant information)
Click here to enter text.
.........................................................................................................................
What information does the referring manager require? (Please select)
What is the nature of the condition affecting the employee’s ability to work?
Is this an underlying health condition?
Click Where there is a medical condition, is this likely to reoccur? If so, what can the University do if it does?
Click
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?
Click Are there any adjustments to be made to allow the employee to return to work or to remain in work?
Click
Is the duration and/or pattern of absence reasonable in relation to the employees condition?
Is the employee capable on health grounds of carrying out the duties of the post for which they are employed?
Click Is the condition likely to be covered under the
Equality Act 2010 or any other relevant legislation?
Click 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?
Click
Should there be any restrictions placed on the employee’s duties? If yes, please give details including timeframes.
Click 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.
Click
Click
Is ill health retirement likely to be supported?
Документ14-1 Jan 2013
Click Any other information you feel would be useful to the University in managing this employee?
Документ1
Click
Page 2 of 5

Please specify any other information required:
Click here to enter text.
…………………………………………………………………………….
……………………………………………………………………………………………………………..…
……………………………………………………………………………………………………………….
Employee comments (to be completed by the employee)
Click here to enter text.
……………………………………………………………………………..
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………….……
Please detail the employee ’s availability (dates and times) for attending to see Occupational
Physician
Click here to enter text.
……………………………………………………………………………..
If you consider that an OH workplace assessment may assist this case, please select here. Click
Please provide any other additional information that may be of relevance
Click here to enter text.
………………………………………………………………………………
……………………………………………………………………………………………………………….…
…………………………………………………………………………………………………………….……
Signed ………………………….…….. Name…………………………… Date……………
Referring Manager
Документ14-0
Документ1
Page 3 of 5

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… Click here to enter text.
……………………………………………..
Date of Birth… Click here to enter text.
........................................................................
Payroll No… Click here to enter text.
..Responsible Manager… Click here to enter text.
Address of Employee… Click here to enter text.
………………………………………….
Employee Contact Number … Click here to enter text.
…………………………………
Job Title of Employee… Click here to enter text.
…………………………………………
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 choose an option 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.
Relating to the Occupational Health report sent to my employer please indicate one of the following options:
Click I do not wish to have a copy of the report from Occupational Health to my Employer.
Click.
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.
Click 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
Документ14-0
Документ1
Page 4 of 5

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)
NOTE 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
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.
Документ14-0
Документ1
Page 5 of 5