EMPLOYEE REFERRAL TO OCCUPATIONAL HEALTH
STRICTLY PRIVATE AND CONFIDENTIAL
GUIDANCE NOTES FOR COMPLETION
To be completed if you require advice from Occupational Health regarding an employee. Please note
that Occupational Health cannot inform management when an employee self refers to Occupational
Health without their consent. Please read the following guidance before completing the form:
Managers must discuss the reasons for the referral with the employee before completing the
Employee Referral form and ensure that the employee is aware of, and understands why they are
being referred.
Section 1: Fully complete the Employee Details section as incomplete details can cause delays in
inviting the employee for an appointment. Please complete the details of the job so that the
Occupational Health team have an awareness of the employee’s duties.
Section 2: Fully complete the Reason for Referral section including absence data where possible.
Section 3: Use this section to indicate the information you would like to receive back from Occupational
Health in the report. Only tick those which are relevant and appropriate to the employee’s referral.
Space is provided for you to ask questions not included in the form. You will receive feedback relating
to the questions that you have asked.
Section 4: The contact details for the referring manager must be completed. Also include the details of
the HR Officer for your area. You must confirm that you have discussed the content of the referral and
the requested feedback with the employee. Occupational Health cannot proceed with the referral if this
has not occurred.
Section 5: To be completed by the HR Officer for your area.
Section 1 – EMPLOYEE DETAILS
Personal Details
Staff ID
Surname
Forename
Date of Birth
Address
(Including
Postcode)
Telephone No
Employment Details
Job Title
School/Unit
Location
Line Manager
Work Pattern
(details of shift)
Hours of Work
Job Description
Is the job description
attached?
Duties:
Yes
No
Physical Demands of the Job
Please indicate the breakdown of workload in percentages if possible:
Office based
Moving and handling
Standing for long periods of time
Computer (DSE/VDU) work
Driver
Forklift truck driver
Food handler
Regular shift / night worker / on call duties
(please specify):
Other duties (please specify):
Work Environment
Contact with biohazards
Contact with chemicals
Exposure to dust
Exposure to noise
Working at height e.g. steps, ladders, roofs
Lone worker
Use of vibrating tools
Hot Temperatures
Ionising radiation
Lasers
Other (Please specify):
Additional information regarding work situation, if applicable.
Section 2 – REASON FOR REFERRAL
Please tick the reason for the referral
Recurrent short term absence
Long term sickness absence
Advice about return to work after long term illness, injury, surgery
Advice regarding adjustments in relation to a disability that the member of staff has disclosed
to you
Work related accident (please include Accident Form number and date sent to EHSS)
Work related ill health
Stress
Identity limitations of ability to undertake work tasks
Are any reasonable adjustments already in place?
If Yes, please specify:
Are there any capability/disciplinary actions in place or pending?
Other (please specify):
Absence Details
Absence details attached?
(for last 3 years)
Yes
No
Yes
No
Is Employee currently on sick leave?
Date current sick leave commenced
Reason for current absence
Current / most recent Medical
Certification expiry date
Additional Information:
Please include any information which you feel may assist the Occupational Health Service in making an
assessment of the case, along with any relevant documentation. If short-term absence – please
describe the pattern and any other useful information.
.
Section 3 – ADVICE REQUIRED FROM OCCUPATIONAL HEALTH
Information required by the Manager from the Occupational Health Service (please tick the appropriate
boxes only)
Is the employee fit to carry out the full range of duties relating to their normal job?
What are the timescales of when the employee is likely to return to work?
Is the employee fit to return to modified duties of work?
If modifications are required are they temporary or permanent?
(please indicate on the form, the type of alternative duties you could accommodate if known)
Is there an underlying health condition affecting their performance at work?
Is the medical problem likely to be caused or made worse by current work activity?
Is the sickness / absence as a result of an accident / illness sustained at work?
Is there an underlying cause for frequent short-term sickness and is it likely to continue?
Does the employee have a disability as defined by the Equality Act 2010 and what adjustments
are advised?
If you have any other questions, please state:
I confirm that I have discussed the content of this referral and the requested feedback with the employee
and that they have agreed to being referred to Occupational Health.
Yes
No
If No, we will be unable to proceed with this referral.
Date the employee was notified of the referral
Section 4 – DETAILS OF REFERRING PERSON
Referring Manager / Designated Officer Name
Designation
Name of HR Officer to receive a copy of the report:
Date of referral
Signature of Referring Person
This document forms part of the clinical notes and is treated in medical confidence.
The content of this document will be discussed with the employee to enable the consultation to be
carried out. With the employee’s consent a report will be provided to the Manager / Designated Officer
and Human Resources as detailed on this form. A copy of the report will also be supplied to the
employee.
There may be a delay before the report can be issued if the employee elects to see the report before it is
supplied to Management / Designated Officer and Human Resources.
Due to the requirement of medical confidentiality, the Occupational Health Adviser / Physician may be
restricted in the type of information they can provide to the Manager/Designated Officer; if so, this will be
indicated in the report.
Section 5 – TO BE COMPLETED BY THE HR OFFICER
Name / Signature of Human Resources Officer
Date received by Human Resources
Date sent to Occupational Health
Please return completed form to Human Resources, The Old Burgh School, Abbey Walk.