This referral should be completed by the Line Manager of the referred employee. LINE MANAGER’S REFERRAL Early Intervention Number (EIN). Provided by OHA Calling 01506 284438 Part A Information for the Occupational Health Professional: – Please give description of the employee’s duties. Give details of the tasks that they perform including physical and mental demands and the nature of their work environment. Activities of the employee: Yes Some No Standing Walking Climbing Working in confined spaces Occupational driving Driving fork lift trucks Driving LGV/PSV Working with chemicals Working with biological agents Working with skin irritants/sensitisers Working with dangerous machinery Exposure to hazards to unborn child/pregnancy Night shift work Exposure to significant work place stress Working with respiratory irritants or sensitisers Lifting or carrying heavy items Handling food Computer work/Display Screen Equipment Prolonged sitting Overseas travel Outside work Noise hazard area Exposure to Hand Arm vibration Exposure to Whole body vibration Using breathing apparatus Working at heights Other (please specify)
This referral should be completed by the Line Manager of the referred employee. LINE MANAGER’S REFERRAL Early Intervention Number (EIN). Provided by OHA Calling 01506 284438 Part A – Information for the Occupational Health Professional: Please give description of the employee’s duties. Give details of the tasks that they perform including physical and mental demands and the nature of their work environment. Activities of the employee: Yes Some No Standing Walking Climbing Working in confined spaces Occupational driving Driving fork lift trucks Driving LGV/PSV Working with chemicals Working with biological agents Working with skin irritants/sensitisers Working with dangerous machinery Exposure to hazards to unborn child/pregnancy Night shift work Exposure to significant work place stress Working with respiratory irritants or sensitisers Lifting or carrying heavy items Handling food Computer work/Display Screen Equipment Prolonged sitting Overseas travel Outside work Noise hazard area Exposure to Hand Arm vibration Exposure to Whole body vibration Using breathing apparatus Working at heights Other (please specify)