1. Guidance on use of OH Referrals is available at www.imperial.ac.uk/occhealth/services/fitnessassessment and in the HR Sickness Absence Policy at http://www.imperial.ac.uk/hr/procedures/health/sicknessabsence.
If you need further advice on whether referral for assessment is appropriate, contact your HR Adviser or an OH Adviser at the College Occupational Health Service.
2. Under ‘Reason for referral’ please provide sufficient information, including information on job performance where this is an issue, for the OH Adviser carrying out the assessment to understand why a medical opinion is being sought at this time. You should also indicate any specific questions you would like addressed in the report.
Note that it is not possible to comment on whether past absences on sickness grounds were justified.
3. The reason for requesting an assessment MUST be discussed with the member of staff and his/her agreement obtained before an appointment is arranged. The person making the referral must confirm this by signing Section B.
4. The member of staff should be given an opportunity to read the completed form before being asked to give his/her consent for an assessment and provision of a report in Section C.
The staff member should sign Section C to confirm their agreement. If the person is off sick, they can sign the consent section when seen in the OH Clinic.
5. Once completed, send the form to the College OH Service. Provide a copy to the member of staff.
6. Assessments are carried out by either a qualified OH Adviser or the College OH Physician. On receipt of a completed form, they are triaged by a senior OH Adviser and the case allocated to the most appropriate person.
7. The OH Service will usually contact the member of staff directly to arrange an appointment. Details of the appointment made will also be sent to the person making the referral.
If you wish for details of the appointment to be sent to the member of staff via you, please indicate this in Section B.
8. If the member of staff does not attend an appointment, the OH Service will advise the person making the referral of this.
9. Reports are usually provided within 2 working days of an assessment or within 5 days if the member of staff requests to see and comment on the report before it is supplied to the referrer. If a longer delay is anticipated, the OH Adviser will advise the referrer of this.
10. A copy of the definitive report is sent to the member of staff and to the HR Adviser for their department at the same time as to the referrer.
11. Reports should be treated as sensitive data: the fitness assessment and recommendations on adjustments to accommodate health problems can be shared with others on a ‘need to know’ basis. An OH report does not usually include confidential medical information. Where it does, the specific consent of the member of staff should be sought before such information is divulged to others.
Clinic Address / Access information
Occupational Health Service
Level 4, Sherfield Building
South Kensington Campus
tel. 020 7594 9401
fax. 020 75949407
/ The College OH Service is on the 4th floor of the Sherfield Building, no. 20 on the campus map. www.imperial.ac.uk/campusinfo/public/sthkencampus.pdf
Access the Sherfield Building using the east entrance, off the main walkway next to the Santander bank branch. The route from the College main entrance provides step-free access.
Allow 15 minutes if walking up from South Kensington tube station.
Wheel chair users, or anyone unable walk more than 100 metres without assistance can contact the OH Office on 020 7594 9401 to arrange an alternative shorter access route.
Notes
Section A: Referral information
1.1 Personal details
Member of staff’s full name
Title / Mr Mrs Ms Dr Prof Other
CID / DOB / Age
Home address
Home telephone number / Home email (if available)
Work telephone number / Work email
Date of starting employment with Imperial College
Date of appointment to present post (if different)
Does the staff member speak English? / Yes No If no, what language is spoken?
1.2 Job details
Job title
Department/ Division
Section
Campus / Please specifyCharing CrossChelsea & WestminsterHammersmithHarefield HospitalNorthwick ParkRoyal BromptonSilwood ParkSouth KensingtonSt Mary'sWyeExternal client
Work location
Usual hours of work
Work pattern / Full-time Part-time Jobshare
Overtime / None Occasional Regular
1.3 Job demands
Tick all relevant boxes
Physical demands / Work hazards
Regular/ frequent exposure to: / Work location / Other demands
Deskwork
Standing
Lifting or carrying*
Computer work
Operating machinery
Driving * / Noise *
Dust or fumes *
Chemicals *
Biological hazards *
Work at heights*
Work in confined space *
Fieldwork *
Travel abroad * / Office
Laboratory
Lecture theatre
Workshop
Outdoors *
Mobile around site
Offsite *
Other * / Teaching
Demonstrating
Clinical work
Management of staff
other significant demand*
Further details, including for asterisked items:
1.4 Current medical issues
Is the member of staff current on sick leave? / Yes No
When does the current medical certificate run to?
What is the reason given for this absence?
1.5 Reason for referral
Why is the person being referred for an assessment at this time?
Tick all appropriate boxes / Concern over attendance
Concern over performance
Concern over welfare/ well-being
Disability assessment
Safety assessment
Assessment after accident at work
Fitness for re-deployment
Consideration for medical retirement
Other please specify:
Details:
Has the person been referred for assessment before? / Yes No
If so, when?
This referral has been initiated by / Line manager
The member of staff
Human resources
1.6 Information requested
Please advise on the following issues:
Is there an underlying health problem that may affect attendance or performance?
If so, when is it likely to be resolved?
If and when the person returns to work, will they be able to carry out the duties detailed on this form and their job description?
Are there any adjustments to duties, equipment or work conditions which may assist the person return to work and/or enable the person to do their job?
Is the person permanently unfit and will they meet criteria for medical retirement?
Other issues as detailed below:
Details:
1.7 Sickness record
Please give details of all health-related absences over the past two years, or since the last referral
Date from / Date to / Number of work days lost / Reason given for absence / Nature of absence / Certificate
New / Continuation / Self / Doctor
Section B: Manager’s checklist
I have explained to the member of staff the purpose of this referral
Tick here if you want appointment details to be sent to the member of staff via you
I enclose: / The person’s job description
Accident report (if relevant)
Any other relevant documents
The member of will be provided with a copy of this form
Name of person making the referral
Position
Telephone number
Work address
Name of HR Adviser
Signature / ______Date ______
If you are filling this form in on computer, save under a new name before printing
Section C: Consent formYour manager/ HR Adviser wants you to attend the College’s Occupational Health Service for an assessment and report on your fitness for work. Your consent is required for this.
All information you provide at an OH assessment is held in medical confidence. The report provides an opinion on the effects of any health problems or disability on your work and advises on support measures that could help you. Specific medical details are only included if it will be of benefit to you for your manager to be aware of them and if you have specifically agreed to this.
You do not have to agree to this assessment. However, if you do not agree and your attendance, performance or conduct is causing concern, then the matter may have to be taken forward without the benefit of medical advice.
At the end of the assessment the OH Adviser will discuss their conclusions with you and outline the content of their report. The Adviser will ask you to confirm that you still consent for the report to be provided. You can, if you wish, arrange to see a copy of the written report before doing so.
I agree to undergo a fitness assessment and for an OH report to be provided to my manager, myself and Human Resources.
Signed ______Date ______
Name ______I
Reports from your own doctor
If the OH Adviser needs to obtain additional information from your own doctor or some other person who has been treating you to complete your assessment, then he/she will discuss this with you and ask for you to sign an additional consent form to obtain this. The OH Adviser will explain to your rights under the Access to Medical Reports Act 1988.
ã Imperial College London Occupational Health 1/5 4/8/2011