PRIVATE AND CONFIDENTIAL

Management Referral Form for

Occupational Health Advice

Employee details
Full name of Employee:		Date of birth:
Department/Faculty/Section/School:
Job title:		Length of employment:
Home address:		Home telephone number:
		Work telephone number:
		E-mail Address:
Reason for referral (please indicate)
Long term sickness absence (greater than 4 weeks) – Employee not presently at work	Resumption after sickness absence – specific concerns regarding capability or safety issues.
Poor attendance – employee at work, attendance/performance issues attributed to health issues	Consideration of Ill health retirement application
Specific health concerns – management concerns for an individual still at work	Accident at work
Additional information – please outline any relevant information regarding reason for referral including the health condition the employee is currently suffering from, if known. Please also attach any relevant supporting documentation, i.e. all sickness absence details, job description, etc., that will help with the assessment.
Please indicate (√) the advice you would like Occupational Health to provide?
Are there any underlying medical problems relating to the attendance record?
Are there any underlying medical reasons for the performance record, as described?
Will the employee be able to give reliable and consistent attendance record on return to work?
Is there any evidence that the work environment has contributed to the current health problem?
Will there be any restrictions or any adjustments on carrying out normal duties?
If yes, please specify and advise how long are the restrictions likely to last?
Will adjustments be temporary or permanent
What are the timescales for recovery and (if presently off sick) for return to work?
Is there any additional help and treatment you could recommend or provide?
When is the employee likely to be able to return to full duties?
Is there a need to consider alternative employment and if so are there any specific requirements e.g. no climbing stairs, no lifting etc
If considered unfit to return to work in the foreseeable future, would you recommend ill health retirement?
Is the medical condition likely to be covered by the Equality Act (formally Disability Discrimination Act)? If yes please provide advice on actions that should be taken.

Additional Information – please provide any additional questions you may have.
Current situation
Is the Employee currently absent from work?
If yes, please provide the start date of their absence:
What is the reason given for their absence?
Please provide any other background information you wish the OHA/OHP to consider This may include information such as recent job changes/adjustments, workplace issues, performance concerns, existing disabilities or any support offered to-date by the University.
Job requirements (please indicate)
Using display screen equipment / VDU Work		Safety critical work (e.g. security)
Shift worker		Working at heights
Night worker		Manual handling
Lone worker		Working with vibrating tools
Driving on University business on a regular basis		Working in noisy environment
Working in confined spaces		Working with chemicals/biological substances
Overseas travel		Working under pressure, exposed to violence/responding to emergency situations
Please provide a brief overview of the employee’s work duties, unless already provided in the job description– attach separate sheet if necessary
To be completed by referring manager
I can confirm that I have spoken to the member of staff about being referred
Name of Referring Manager:	Date of Referral:
Position of Referring Manager:	Contact Telephone No:
HR Contact	HR Contact (E-mail address and phone)