Section 1 Personal details Name of employee Payroll number Job Department Line-manager HRBP Contact Employee Contact telephone no. Date of Initial referral Reason for referral Health related performance issues Possible work related health problem Rehabilitation Sickness absence Other (please state) ………………………………………………………………. For HR completion Triage date Refer to Occ Health Adviser for next available appointment Defer for referral until date………………………………………. because Triage outcome ………………………………………………………………………………………………………. Decline referral because ………………………………………….............. ………………………………………………………………………………………………………. Section 2 Supporting Information Current job description Copies of Fit notes for the relevant period Sickness Absence record Risk Assessment / DSE Assessment form Letter from doctor/consultant/counsellor/etc. Section 3 Nature of current role Please provide a description of the individuals working environment to include number of individuals in team, nature of work (whether physically demanding, requiring travel, office based, use of a pc, degree of repetition of tasks, hours of work, shifts, anti-social working hours etc). The recommendations of the OHA will be informed by this information so please provide as much detail as possible.
Section 1 Personal details Name of employee Payroll number Job Department Line-manager HRBP Contact Employee Contact telephone no. Date of Initial referral Reason for referral Health related performance issues Possible work related health problem Rehabilitation Sickness absence Other (please state) ………………………………………………………………. For HR completion Triage date Triage outcome Refer to Occ Health Adviser for next available appointment Defer for referral until date………………………………………. because ………………………………………………………………………………………………………. Decline referral because ………………………………………….............. ………………………………………………………………………………………………………. Section 2 Supporting Information Current job description Copies of Fit notes for the relevant period Sickness Absence record Risk Assessment / DSE Assessment form Letter from doctor/consultant/counsellor/etc. Section 3 Nature of current role Please provide a description of the individuals working environment to include number of individuals in team, nature of work (whether physically demanding, requiring travel, office based, use of a pc, degree of repetition of tasks, hours of work, shifts, anti-social working hours etc). The recommendations of the OHA will be informed by this information so please provide as much detail as possible.
Occupational-Health-Referral-Form.docx