Optima Health

F-CG-082

/

OPTIMA HEALTH

/ F-CG-082 (WLC)
Issue 6 – 29/5/18
REFERRAL FOR OCCUPATIONAL HEALTH Assessment WLC
* Please ensure these fields are completed, we are unable to process requests without this information.
Service Area* / Choose an item. / Functional Area* / Choose an item. /
Referring Manager* / Click here to enter text. / Date of request* / Click or tap to enter a date. /
Tel. No.* / Email address
Work address*
HR Contact name* / Choose an item. / HR email* / Choose an item. /
OPTIMA HEALTH accepts this request ONLY on the understanding that the employee below is fully aware of this referral.
Employee’s name* / Employee Number* / Sex
M F
Home address* / Date of Birth*
Click or tap to enter a date.
Sex*
M F
Office address* / Email address*
Phone:
Is the employee absent from work? * / Job Title
Condition leading to referral
Please provide any dates or periods the employee will NOT be able to attend an appointment
Date employment commenced: / Click or tap to enter a date. / Date absence Commenced*: / Click or tap to enter a date. /
Main Reason(s) for Referral - Please indicate with 
Short term sickness absence - please attach sickness absence record
Long term sickness absence - please attach sickness absence record
Fitness for work concerns
Report after accident at work (please attach details)
Job modification / pre-promotion
Performance deterioration
Other reason, including mobile screening referral (please specify)
Fitness to attend a disciplinary hearing
Are there any disciplinary warnings in force in relation to this referral? / Yes / No
Has the employee been consulted about this referral? / Yes / * / No
Is the reason for this referral reportable to the HSE under RIDDOR / Yes / No
This referral should be completed by the Line Manager of the referred employee.
LINE MANAGER’S REFERRAL
Early Intervention Number (EIN). Provided by OHA Calling 01506 771730 / Click here to enter text. /
Part A – Information for the Occupational Health Professional:
Please give description of the employee’s duties. Give details of the tasks that they perform including physical and mental demands and the nature of their work environment.
Activities of the employee: / Yes / Some / No
Standing
Walking
Climbing
Working in confined spaces
Occupational driving
Driving fork lift trucks
Driving LGV/PSV
Working with chemicals
Working with biological agents
Working with skin irritants/sensitisers
Working with dangerous machinery
Exposure to hazards to unborn child/pregnancy
Night shift work
Exposure to significant work place stress
Working with respiratory irritants or sensitisers
Lifting or carrying heavy items
Handling food
Computer work/Display Screen Equipment
Prolonged sitting
Overseas travel
Outside work
Noise hazard area
Exposure to Hand Arm vibration
Exposure to Whole body vibration
Using breathing apparatus
Working at heights
Other (please specify)
What are the employee’s normal hours? Does the employee regularly work additional hours in excess of their normal contractual hours? If yes, please give details.
Have you noticed any change in the employee’s performance or have they advised you of any problem that they have been experiencing? For example: difficulty in using equipment, travelling to work, general attitude, discipline, time-keeping, behaviour towards colleagues, domestic/personal problems, coping with change, health (long term/short term absence or other factors that they have identified). Please give details and explain the impact on the working environment in terms of colleagues and day-to-day operations (continue on a separate sheet if necessary).
Please give details of actions taken so far to address the problems outlined in this report. Continue on a separate sheet if necessary. Please relate any actions taken in respect of the following:
Long Term Absences (20 working days or longer)
In order to prevent absent colleagues becoming isolated and to encourage them to return, it is important that arrangements are made to keep in touch with them. We would advise you to keep records of such contacts to show that you have acted as a reasonable employer. Outline difficulties you have had in maintaining contact.
Please state what arrangements you have made. Give details of any Keep In Touch visits/discussions you have undertake, including the records of any visits/interviews held.
If appropriate, give details of any possible difficulties that the employee has indicated in being able to travel.
Part B – Referral Questions you wish to be addressed by the Occupational Health Professional:
Below is a standard list of questions that can be covered in the report following referral. Please tick if a response is required and use the space provided to detail any other questions that you would like answered.
Standard and/or Optional Questions / 

1. Is there an underlying cause for this sickness absence?

1. Is the condition work related? If so how?

1. Is the employee fit to carry out their normal duties at present?

1. When is a return to work likely? Please outline anticipated timelines and any risk to a return within them.

1. Is a gradual return to work recommended? If so, what rehabilitation arrangements are appropriate?

1. Could the employee undertake light/alternative duties?

1. Would the medical condition be likely to be classified as a Disability under the Equality Act?

1. If the employee has an underlying health issue would a relaxation of trigger levels support the employee in returning to work and sustaining their attendance at work?

1. Are there adjustments that the employer could make to support the employee at work or help facilitate a return to work?

Specific Additional Questions
Please use the space below to ask amaximum of 2 further questions if required.
Has the employee consented to a telephone consultation (if deemed suitable) and provided a working telephone number for these purposes? *(please provide number at start of referral) / Yes / ☐ / No / ☐ /
I understand that this referral will become part of the OH record and will be disclosed to the employee on request
Manager’s Signature: / Date: / Click or tap to enter a date. /
Data Protection
Optima Health recognises the importance of respecting the personal privacy of all customer data and the need to build in appropriate safeguards during the collection, storage, processing and utilisation of personal data.
Optima Health will comply with the requirements of all relevant data protection legislation. Information will be collected and used fairly, stored safely and not disclosed to any person unlawfully. Optima Health acts in the role of Data Controller and Data Processor for customer data.
For further information on how we manage your data please see our data protection policy at

Please email completed form to

Page 1 of 5

Optima Health In Confidence