Management referrals - Occupational Health Advisor - Health Management

Is the referral related to the individual’s bones, muscles, joints, back, upper or lower limbs?*
Is the individual in what would be considered a safety critical role?*
Is the referral related to stress, anxiety or depression and is this the reason for the referral?*
Has the individual had a serious mental health issue or has made the employer aware of an addiction that is having an impact on their work and this is the reason for the referral?*
As a result of the advice given following the assessment, are significant employment decisions likely to be made?*
Is there a possibility that the individual may have a problem with a telephone assessment?*
Is there a possibility that the individual may have a problem with attending a clinic for a face-to-face assessment?*
Is the referral related to Covid 19 and the individual’s underlying health condition or your risk assessment in relation to the health and working environment?*
Contact details
About you HR/Manager
Your first name*
Your surname*
Your email address*
Your phone number*
Your company name*
About your employee
Employee first name*
Employee surname*
Employee Date of Birth*
Date Format: MM slash DD slash YYYY
Employee Gender*
Employee email address*
Employee phone number*
Employee Address*
Street Address Address Line 2 City Postcode

Advice I would like
I would like to know:*
- When the employee is likely to return to work
- Is the employee fit to continue in their current role?
- Is the employee’s absence or health concern related to their work?
- Are workplace adjustments recommended?
- Is the employee’s attendance likely to be affected in the future?
- Does the employee have a health condition that is likely to impact on their performance?
- If the case is covered by The Equality Act 2010
Please tick as many boxes as needed
Please add any additional information that will help the clinician conducting the assessment to understand the context and provide the best possible advice.

Adjustments for employee

Please tell us about any adjustments that you have currently made for the employee and/or any future adjustments that you can consider that are reasonable
Time
e.g. reduced hours, changed working hours, changed shift pattern
Time - Current Adjustments
Time - Future Adjustments
Tasks
e.g. reduced tasks, extra time to complete tasks
Tasks - Current Adjustments
Tasks - Future Adjustments
Work environment
e.g. adjusted lighting, ground floor workstation, close to toilet facilities
Work environment - Current Adjustments
Work environment - Future Adjustments
Workplace support
e.g. access to a mentor, access to a counsellor, retraining
Workplace support - Current Adjustments
Workplace support - Future Adjustments
Workstation
e.g. monitor riser, ergonomic chair, ergonomic mouse and keyboard
Workstation - Current Adjustments
Workstation - Future Adjustments
Travel
e.g. lift share scheme, changes work location, home working arrangements
Travel - Current Adjustments
Travel - Future Adjustments

Support Information
Please attach a job description and a copy of the employee’s sickness absence record (if available)
Drop files here or

Employee consent
Declaration*
I confirm that the employee is aware of the reason for my referral to Health Management and I have informed them that appropriate personal data will be provided to Health Management to progress the referral

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