Occupational Health, Safety and Wellbeing

be well, be safe

Occupational Health Service Management Referral

Section One

Employee:
Surname: / First Name:
Previous Surname
(if applicable): / Date of Birth:
Address:
Home Telephone: / Work Telephone:
Mobile:
Contact Email:
Job Title:
Directorate: / Department:
Site: / Employee Number:
Manager
Name: / Telephone:
Personal Work Email:
School
(if relevant):
Department: / Section:
Site: / Date of Referral
Human Resources Advisor

Occupational Health, Safety and Wellbeing

be well, be safe

Are there any specific times of the day when the employee will be unavailable for appointments, for example, annual leave, holidays. Please provide details where relevant.

Section Two - Please indicate reasons for referral.

Please read guidance notes before completing the next sections.

Short term sickness absence:
Long term sickness absence:
Work related health concern:
Performance affected by a health issue:
DSE/ergonomic referral - please attach completed DSE risk form:
Ill health retirement:
Fitness to attend disciplinary or grievance meetings:
Other reason - please state in Section 3

Section Three - Absence details

Reason for referral. Please read guidance notes before filling this part in.
Questions which will be answered:
  • If the employee is likely to be fit to return to work and if so, when.
  • Any adjustments are necessary, in terms of hours, duties, the work or the working environment, to facilitate a return to effective health and work.
  • The employee is covered by the Equality Act 2010.
  • An occupational health review has been booked.

Please provide any further questions not included in the above:
Is the employee currently at work? / Yes No / Return to work date:
Have you gained the employee’s consent to attend Occupational Health? / Yes No / Date obtained:
Is the employee fully aware of why they are to attend Occupational Health? / Yes No / Date information provided:
Signature: / Date
Verify the following before sending the form to Occupational Health Service.
Evidence has been obtained of sickness absence of the last three years.
Please ensure this is sent to Occupational Heath with this form.
Do you want a copy of the report sending to Human Resources? / Yes No
Company providing human resources services - schools only:
Human Resources email address:

Once completed in full, please save in a confidential personnel file for your employee and forward document to -