Management referral to
occupational health (A2)
To refer a member of staff to the University’s Occupational Health Service for an assessment and advice on
health issues affecting their work, please:

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Complete all the appropriate sections of this form
Provide relevant background information
Discuss this referral with the staff member concerned and obtain their consent to request the
information required
This referral will form part of the member of staff’s clinical records, to which the member of staff has access
if requested.
Detailed guidelines about management referrals are available on the HR website at
www.southampton.ac.uk/hr/services/occupational_health/index.php.
1.
EMPLOYEE INFORMATION
Full name:
Date of birth:
Employee number:
Job title and level:
Academic Unit/Service:
Home address:
Telephone number:
Mobile number:
Email:
2.
LINE MANAGER INFORMATION
Full name:
Job title:
Academic Unit/Service:
Telephone number:
Email:
3.
HR MANAGER INFORMATION
Full name:
Telephone number:
Email:
4.
REFERRAL DETAILS
Date of referral:
Is the member of staff currently off sick/at work?
Yes/No
Did the member of staff give their consent to this referral?
Yes/No
Has the reason for the referral been discussed with the employee?
Yes/No
Does the employee have a full-time or part-time contract?
Full-time/part-time
If part-time, please indicate the days and hours that they work:
In your opinion, should an application for ill health retirement be
supported in this case?
Yes/No
Is the health issue work related?
Yes/No
5.
REASON FOR REFERRAL
Please mark as applicable.
Long-term sickness absence
Intermittent short-term sickness absence
Health related performance issues
Job requirements have changed/will be changing
Possible work related health problem
Suspected substance abuse
Other – please supply details on the next page
6.
DATES OF ABSENCE OVER LAST 12 MONTHS
Please supply as applicable.
Start date
7.
End date
Reason
Certification (self/medical)
INFORMATION REQUESTED
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Please identify if any of the information below is required by the manager from the referral (mark all
applicable).
What is the likely timescale for recovery and/or when do you anticipate a return to work?
Is there an underlying medical condition affecting this individual’s performance or attendance at work?
Is he/she fit to carry out the full range of duties of his/her current role?
Are there any short-term adjustments to the role / environment that would help facilitate rehabilitation
or an early return to work?
Are there any reasonable permanent adjustments to the role or environment that can be recommended?
Is there further requirement for medical support or intervention?
Will he/she be able to offer a regular and efficient service in the future or is this health problem likely to
recur or affect future attendance?
In your professional opinion is the health problem likely to meet the criteria for disability as defined by
the Equality Act 2010?
Should the individual be considered for redeployment on medical grounds?
8.
FURTHER INFORMATION
Reason for referral and specific advice required and/or relevant information. Please ask any questions that
you feel are not covered in the previous section and will help with the management of this case. This section
may be expanded as required and any relevant supporting documentation should be attached.
Reason for referral and specific advice required
9.
JOB REQUIREMENTS
List specific requirements of the job (mark if applicable).
Repetitive upper limb movements
Repetitive lower limb movements
Repetitive bending/stooping
Prolonged standing
Working at height
Use of display screen equipment
Use of vibrating tools
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Food handling
Driving (for work purposes)
Contact with respiratory sensitisers/irritants
Contact with dermatological sensitisers/irritants
Other
 Please not e- a copy of the employee’s current job description should be submitted with the referral.
10. AUTHORISATION
I confirm that I have discussed the reason for this referral with the member of staff and they are aware of the
information being requested. I understand that this document will form part of the member of staff’s
medical record and as such they have right of access to it under the Data Protection Act 1998.
Referring manager’s name
Date
I confirm that the reasons regarding this referral have been discussed with me and I consent to a report being
prepared by the occupational health department in relation to this referral.
(This may not be applicable if the member of staff is absent due to ill health.)
Employee’s signature
Date
11. RETURN TO
Please submit the completed form and any supporting material (including a current job description) to your
dedicated HR Manager by email.
Your HR Manager will then direct the referral to the OH Service and, following assessment of the staff
member, a report sent to the referring manager and HR Manager.
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