OCCUPATIONAL HEALTH

MANAGEMENT REFERRAL FORM

FOR OCCUPATIONAL HEALTH ASSESSMENT AND ADVICE

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PRIVATE AND CONFIDENTIAL

This form is confidential to Occupational Health (OH). Once completed by the Manager / Employee Relations Adviser responsible for the employee, please send either by post to the Occupational Health Service, Room 4N.6.2, University of Essex, Wivenhoe Park, Colchester, Essex CO4 3SQ or by email to ohquery@essex.ac.uk

Please complete this form using the “Guidance for Managers: Completing an Occupational Health Management Referral Form” document. We will be unable to process the referral if the form is not completed in full.

Employee details (This section must be completed)
Title:	Pronouns:	Full name:
Department/Faculty/Section/School:	Date of birth:
Job title:	Date employment commenced:
Please indicate the employee’s preferred method for OH to inform them of their appointment: Work email Personal email Telephone Letter
Home address:	Telephone number (this will also be the number used for telephone appointments if applicable):
Personal e-mail address if applicable:
If the employee would like to receive a text reminder a few days prior to their appointment, please provide their mobile number here:
Which campus is the member of staff mainly based at? Colchester Southend Loughton
Referring Manager’s details (This section must be completed)
Name:	Contact telephone No:
Position:	E-mail:
Employee relations advisor contact name (if known)
Current work status (This section must be completed)
Is the member of staff currently at work? Yes No	If not at work, please provide the following details. Date absence commenced: (If not given above) Personal email: Telephone number:
Is the member of staff on a phased return? (If yes, date started and number of hours working on a phased return)
Normal working hours/working pattern:	Is the member of staff working overtime in their current role, or engaged in other employment?
Reason for referral (Please mark the most relevant option)
Frequent short term sickness absence (Please supply separate summary of sickness absence in the last 12 months only)
Long term sickness absence	Consideration of ill health retirement
Impact of fitness/health to perform current role	Accident/Incident at work
Fitness to return to work after illness/injury	DSE Advice
Wellbeing support	Concerns about occupational diseases
Other (Please state):
Reason for referral (This section must be completed) (Include relevant background information such as recent job changes/adjustments, workplace issues, performance concerns, existing disabilities or any support offered to date by the University. Please refer to “Guidance for Managers: Completing the Occupational Health Management Referral Form”)
Please continue on a separate sheet if required
Are there any work performance issues? (This section must be completed)
YES / NO (If yes, please explain):
What are the specific questions you would like OH to answer to help you manage the situation? (This section must be completed) It would be helpful if you could number your questions. Example questions can be found on the guidance document for managers completing the referral form.
Please provide any additional relevant information:
Job requirements (Please tick all that are applicable)
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 attach a job description with this referral. If this is not available, please provide a brief overview of the employee’s work duties. Please ensure this section is completed if a job description is not available.

Referring Manager Information
Please note: The referral will be shared with the employee and used as the basis of their consultation in Occupational Health. Occupational Health will need to obtain consent from the employee to send the Occupational Health Report based on the consultation. If the member of staff withholds their consent, you have to proceed without the benefit of Occupational Health advice. It is the referring manager’s responsibility to provide Employee Relations (hrer@essex.ac.uk) and the employee with a copy of this referral It is the referring manager’s responsibility to update Occupational Health on any changes that may affect the employee’s referral, prior to their assessment. Please ensure the employee is advised that all correspondence regarding their assessment will be via their university email address, unless requested otherwise.
I confirm that I have read the above information and have spoken to the employee, providing them and ER with a copy of this referral. Name: Signature: Date: