Management Referral Form
Management Referral form V2.0
Delegate Details
Full Name
*
Date of Birth
*
Address - First Line
*
Address - Town
*
Address - County:
*
Address - Post Code:
*
Phone
*
Employee Email
Occupation Details
Company Name
*
Work Location
*
Emplyee Job Title/Position
*
Date of Consultation
Referral Details
Upload the job description
Drop a file here or click to upload
Choose File
Maximum file size: 10MB
Reason for referral
Details of problem
Questions you would like answered by Occupational Health Service: (A sample is listed below). Please delete what is not required
Has the referral been discussed with employee. Employee must be aware of content within the referral
Yes
No
Sample Questions
Please consider these questions when you are thinking about the referral they will help us to best asses the patient.
Is there an underlying health condition causing their sickness absence/symptoms?
Is there any evidence that the work environment is contributing to the sickness absence/performance issues?
Is there any additional help/treatment you could recommend?
When are they likely to return to work/normal duties?
Does the Equality Act (2010) apply in this instance?
Is the condition likely to cause sickness absence in the future?
Would you recommend any temporary or permanent adjustments to the employee’s duties now or when they return to work?
Please indicate what modifications should be made?
For how long should these modifications continue?
In relation to their attendance at a disciplinary meeting, will they be able to:
Understand the issues to be discussed?
Make a meaningful contribution to the discussion
Advise a representative of what they want
Follow the discussion
Understand the decisions made?
DECLARATION
I understand that I am being referred to the Occupational Health Service and give my consent to a report being prepared for Management/HR.
Consent
*
I have consent from the employee to make this referral and for the content in the referral.
Referral Type - Requested
Please Select
Face to face
Telephone Consultation
Teams Consultation
Enter your full name to confirm the above information
*
Email Address
*
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Option 1
Option 2
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