Self Referral To
Occupational Health - Staff
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
Completed forms should be sent to The University of Nottingham Occupational Health
Department, Cripps Health Centre, University Park, Nottingham NG7 2QW.
1. Employee Details
(Employee to complete)
Your Name: Click here to enter text.
Mr/Mrs/Ms/Dr: Click (BLOCK CAPITALS PLEASE)
Job title: Click here to enter text.
Faculty: Click here to enter text.
School/Dept: Click here to enter text.
Division (if applicable): Click here to enter text.
Location/Site at Work: Click here to enter text. Manager’s Name:Click here to enter text.
Date of Birth: Click here to enter text.
Payroll No:Click here to enter text.
Work Tel No: Click here to enter text.
E-mail address:Click here to enter text.
Home address: Click here to enter text.
Home Tel No: Click here to enter text. Mobile Tel No: Click here to enter text.
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.
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2. Referral Details
(Employee to complete)
My reason for requesting this referral is as follows:
Click here to enter text.
Please describe your job in as much detail as possible including weights lifted and repetitions required: (Please
attach a job description if available)
Click here to enter text.
Amount of sick leave taken in past year (attach copies of any sick notes or other relevant information):
Click here to enter text.
If there are any dates where you would not be available to attend Occupational Health, please give
details below:
Click here to enter text.
Please provide any additional information here:
Click here to enter text.
Signed …………………………………….…Name Click here to enter text. Date Click here to enter a date.
Referred Employee
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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: Click here to enter text.
Date of Birth: Click here to enter text.
Payroll No: Click here to enter text.
GP Name address and contact details:
Click here to enter text.
Specialist Name address and contact details:
Click here to enter text.
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:
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.
Signature:..................................................Name (Print): Click here to enter text. Date: Click here.
Referred Employee
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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 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.
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