ࡱ> g Ībjbj:: 4X jX j` ` CCCWWWWW+j?t<J (+*+*+*+*+*+*+$.51TN+QCjx"jjN+?9+N"N"N"j"8C?(+N"j(+N"N":',+H(' MdF' ++0+'R2&2H(H(2C(LjjN"jjjjjN+N+Vjjj+jjjj2jjjjjjjjj` Y :  ý Occupational Health Referral Form  Managers InformationName:Academic School/Service Department:Contact Number:Date of Referral:Employee InformationName:Address:Date of Birth:Contact Phone Number: FORMTEXT      Email address:Job Title:Hours of work (per week):Date the employee was made aware of referral:Date started in post:Please indicate the preferred method of contact with the individual: Mobile  FORMCHECKBOX  Telephone  FORMCHECKBOX  Email  FORMCHECKBOX  Letter  FORMCHECKBOX Please indicate the individuals preferred method of assessment: Face to Face  FORMCHECKBOX  Teams (online video)  FORMCHECKBOX  Telephone  FORMCHECKBOX  HR Manager InformationFull Name: Reason for Referral & Specific Advice RequiredLong Term (including advice on phased return to work): Intermittent Absence: In work (Welfare Referral): Immediate Referral (Stress/Musculoskeletal):  Management Contact: Details of last contact with staff member if on long term sickness absence:  Referral Details It is essential you provide as much background information as possible about why you are referring the employee, which may include length and reason for absence/ absence history/ dates and details of the Fit Notes/ the nature of the employees role and the impact the condition appears to be having on their ability to perform their duties/ what adjustments have already been put in place/ what support has been offered. If appropriate to the referral, please include details of any formal management processes the employee is currently involved in.  **Please tick all the questions which you would like Occupational Health to answer.** (please ensure you refer to the guidance notes when completing this section)1What is the likely timescale for recovery and/or when do you anticipate a return to work? 2Is there an underlying medical condition affecting this individuals performance or attendance at work? 3Are they fit to carry out the full range of duties of current role?  4Are there any short-term adjustments to the role/environment that would help facilitate rehabilitation or an early return to work 5Are there any reasonable permanent adjustments to the role or environment that can be recommended? 6Is there further requirement for medical support or intervention?7Will they be able to offer a regular and efficient service in the future or is this health problem likely to recur or affect future attendance?8In your professional opinion is the health problem likely to meet the criteria for disability as defined by the Equality Act 2010?  + + 9Should the individual be considered for redeployment on medical grounds?10Should the individual be considered for Ill Health Early Retirement? Confirmation of discussion with individual being referred:I can confirm that the individual has been made aware of this referral and a copy has been provided to them ahead of being referred to Occupational Health Managers Signature: Date: ..  Checklist of attachments:1Sickness Absence record (previous 12 months)2Job Description3Any other relevant information please identify4Details of last contact with the Individual if absent from work e.g. Telephone contact, email contact or meeting with individual. Please include dates. 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