Hours of work Overtime Night duties VDU work Manual Handling Driving Type of vehicle Breathing Additional hazards machinery Climbing ladders apparatus (please tick): Working at height Biological Confined spaces Chemical exposure agents Lasers Working in Isolation Non Ionising Radiation Ionising Radiation Mental pressure Respiratory Dust, fumes powder exposure Food handling Work with Static posture Travel overseas animals Field work Exposure to noise Other (please detail) c. Reason for Referral (please tick boxes and give relevant supplementary information in the box below to fully explain your concerns) Sickness and Absence complete section D or attach document containing absence – information Recurrent short spells of absence causing concern Prolonged sickness absence Date when sickness absence commenced Diagnosis on medical certificate (Med 3) Combination of short and long term absence Trigger Point Under Managing Sickness Absence Procedure Concern regarding fitness for work. Please provide examples of activities affected and how the individual is affected; with specific reference to work tasks, as pertinent, (Use box below.) “Additional Information” Report following accident at work Assessment prior to job alteration Concern that health may be impacting on performance. Please state what, in referrer’s opinion, is the impairment, how has it been identified and how long has it been in existence. (Use box below) “Additional Information
Hours of work Overtime Night duties VDU work Manual Handling Driving Type of vehicle Additional hazards (please tick): machinery Climbing ladders Breathing apparatus Confined spaces Working at height Chemical exposure Biological agents Working in Isolation Non Ionising Radiation Ionising Radiation Lasers Mental pressure Respiratory Dust, fumes powder exposure Static posture Food handling Travel overseas Work with animals Field work Exposure to noise Other (please detail) c. Reason for Referral (please tick boxes and give relevant supplementary information in the box below to fully explain your concerns) Sickness and Absence – complete section D or attach document containing absence information Recurrent short spells of absence causing concern Prolonged sickness absence Date when sickness absence commenced Diagnosis on medical certificate (Med 3) Combination of short and long term absence Trigger Point Under Managing Sickness Absence Procedure Concern regarding fitness for work. Please provide examples of activities affected and how the individual is affected; with specific reference to work tasks, as pertinent, (Use “Additional Information” box below.) Report following accident at work Assessment prior to job alteration Concern that health may be impacting on performance. Please state what, in referrer’s opinion, is the impairment, how has it been identified and how long has it been in existence. (Use “Additional Information box below)