Human Resources
Management referral to Occupational Health Services
Long Term Absence
Employee details (to be completed by HR)
Title Prof, Dr, Mr, Mrs, Miss, Ms …………………………………………………........
Name ……………………………………………………………………………………..
School/Unit/Residence ………………………………………………………………….
Employee Number………………………………………………………………………
Date absence commenced ………………………………………………………………
Dates of current medical certificate …………………………………………………...
Diagnosis on current medical certificate………………………………………………
Dates of last previous absence …………………………………………………………
Refer to Occupational health
 Yes *(complete section A)
 No *(complete section B)
Section A
I.
Date employee was notified of management referral ……………………….
II.
Job description/list of duties attached

OR
Please provide a brief description of the duties and responsibilities carried
out:
………………………………………………………………………………………….
………………………………………………………………………………………….
.…………………………………………………………………………………………
..………………………………………………………………………………………..
III.
Please provide any relevant background information or management
concerns:
………………………………………………………………………………………….
.……….………………………………………………………………………………
…..……………….……………………………………………………………………
……..……………………….…………………………………………………………
IV.
Please detail what information you would like OH to provide/explore over
and above likely return date and/or reasonable adjustments.
………………………………………………………………………………………….
.……….………………………………………………………………………………
…..……………….……………………………………………………………………
……..……………………….…………………………………………………………
Section B
Please provide reasons for not making referral:
………………………………………………………………………………………….
………………………………………………………………………………………….
.…………………………………………………………………………………………
Signed …………………….…………………………………
Date ………………………
Completed forms should be returned to Human Resources, College Gate, North
Street or by email to geo@st-andrews.ac.uk.