*Before completing this form, please ensure you have all the relevant medical information available
Job Details
Summary of role
Impact of absence
Particular aspects of the role staff member must be able to do
Reason for Referral
State if health problem is affecting performance, fitness & attendance or if there are any current performance issues/processes underway
Sickness Absence Record
State the reason, duration and frequency of absence for the last 12 months including current absence if off sick
Adjustments/Support
Outline any adjustments/support which have already been made and also what adjustments cannot be accommodated and reason
What questions do you want answered?
i.e. would you like to know about
I confirm that this referral has been discussed with the staff member. He/she/they are aware of the reason(s) for the referral and agrees to attend an appointment. (Please note OH cannot see the staff member unless they have been advised of the reason for the referral).
Please tick here
If you need to discuss this referral in further detail please contat the Occupational Health service on:
Tel: 01227 286288 | Email: payg@ohworks.co.uk
Where we are able to contact the staff member by telephone we will aim to offer an appointment within 5 working days. If we are required to contact them by post an appointment is likely to be 5-10 working days as we need to allow the post to reach them. Please therefore provide the staff member's phone details wherever possible.
We aim to provide a written report with 48 hours of the appointment.
