CONFIDENTIAL OCCUPATIONAL HEALTH REFERRAL FORM – School based employees

Please note: Head teacher must discuss this referral with the employee and ensure that he/she receives a copy of it.

Head teacher to complete ALL sections below and then send to

Does the school buy the NCC HR package? / Yes / No

HUMAN RESOURCE CONTACT DETAILS (to be filled in by NCC HR section only)

HR contact allocated, if HR service bought back / Date received
E-mail: / Tel. No:

1. EMPLOYEE DETAILS

Surname / Forenames
Home Address / Date of Birth (dd/mm/yyyy)
National Insurance No
Employee No
Home Tel. No
Mobile Tel. No
Work Tel. No / Email address if the employee prefers to be contacted by the Occupational Health Service by email:
Please indicate which pension scheme the individual belongs to? / Local Government / Teachers / None

2. EMPLOYEE JOB DETAILS

Job Title / Workbase
Weekly Hours / Days of Week
Date of commencement with NCC
If the employee has more than one job either within NCC or externally, give details of the other job(s)

3. REFERRING MANAGERS DETAILS

Name / Department
Job Title / Team/workplace
Telephone Number / Email
Cost code to be used when a GP/Specialist report is required
Name of budget approver

4. REASON FOR REFERRAL

Long term sickness absence / Persistent short term sickness absence / Other
If you have ticked ‘other’ please state reason
If the Occupational Health report is required by a specific date please indicate date and reason
Date (dd/mm/yyyy)
Reason

5. ABSENCE INFORMATION

Start Date of current absence
(dd/mm/yyyy) / End date of current medical certificate dd/mm/yyyy)
What is the stated illness or condition
If stress related,haveyou considered conducting a wellbeing survey for the team?
Yes No
(Please contact the Occupational Health team for further details)
Has the employee declared that they have seen their GP and/or specialist? / Yes / No
If Yes please give details
Has the employee declared that they are currently taking any medication or receiving any treatment for their condition/symptoms? / Yes / No
If Yes please give details
Sickness absence record, with reasons for preceding 2 years enclosed? / Yes / No
If relevant, date of last Occupational Health Referral (dd/mm/yyyy)

6. HAZARDS AND RISKS ASSOCIATED WITH THE JOB (Please tick relevant box(es))

Moving and Handling / Lone Working / Challenging behaviour / Computer work
Hot temperature eg
boiler House / Outside working / Frequent hand
washing / Driving
Work at height eg ladder/roofs / Vibrating Tools / Exposure to dust, fumes, gases, silica, vapours flour etc
Please give further information of the hazard/risks indicated above i.e. length of time/frequency of use/exposure
Please also indicate any further specific job tasks associated with the employees job i.e. traffic management, personal care etc
Please explain how their health problem is affecting the employee’s ability to do their job
Is the employee currently subject to capability, attendance or disciplinary procedures or have they been advised that proceedings are being considered? / Yes / No
If YES, please advise which procedure and the date that this commenced
Please also give brief details of circumstances if appropriate and relevant to the referral

7. ADJUSTMENTS TO HELP THE EMPLOYEE UNDERTAKE THEIR JOB

Have you as the Manager considered or
are able to consider: / Could
consider / Implemented / Not able to
consider
Reduction in working hours?
Phased return to present duties?
Temporary change in work
activities?
Temporary change to work location?
Additional training?
Have you completed a risk assessment? / Yes
(enclosed) / No
Has the employee been made aware of the following (if appropriate) / Yes / No
Access to Work
CounsellingService
Physiotherapy Service
Please explain further on the above answers and any additional measures considered or implemented

8. Questions YOU want OCCUPATIONAL HEALTH to answer - Tick the questions which identify your KEY concerns

Is this condition permanent or temporary?
What is the likely timescale for a return to work in their current post?
Is the condition caused or made worse by work/job?
Would their condition fall under the remit of the Equality Act?
Are they receiving treatment?
With treatment, will their ability to carry out their normal duties improve in the
foreseeable future?
Is there any medical reason as to why they can’t perform their current role?
Please advise of any adjustments needed to help the employee to undertake their
duties.
Should redeployment be pursued? Please provide details of potential suitable areas
of work and whether this is a temporary or permanent change.
Is there an underlying health condition accounting for their persistent absences?
Is the employee fit to attend a formal hearing?
Do they require a phased return to work?
Would this person’s condition meet the medical criteria for ill-health retirement?
Other?
If ‘Other’ give details

9. EMPLOYEE AVAILABILITY

Please indicate any specific date(s) that the employee is unavailable to attend e.g. hospital appointment/holidays

DECLARATION

I will ensure the employee is reminded of the appointment details and I understand that if they cannot attend the allocated appointment, they have been advised to contact me in the first instance to discuss their reasons. / Yes
I further understand that if the employee does not attend an appointment for any reason without giving 2 days’ notice, the school will be liable for a cancellation charge, in accordance with the Services for Schools contract. / Yes
I have discussed this referral, and possible outcomes, with the employee and will ensure he/she has a copy of it prior to his/her appointment.
Date of discussion: / Yes
Date (dd/mm/yyyy)
Signature of Head Teacher / Date (dd/mm/yyyy)

This document will form part of the employees Occupational Health Records to which they have a right of access (Access to Medical Records Act 1990 and/or Data Protection Act 1998).

Updated 1.4.14.