F-CG-155 Issue 1 –12/03/14 (WLC Issue 2 09/08/16)

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OPTIMA HEALTH

/ F-CG-155
Issue 1 – 12/03/14
(WLC Issue 2 09/08/2016)
REFERRAL FOR HEALTH SURVEILLANCE
* 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 here to enter a date.
Telephone No*: / Click here to enter text. / Email address*: / Click here to enter text.
Work Address*: / Click here to enter text.
HR Contact Name* / Choose an item. / HR Email address* / 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*: / Click here to enter text. / Employee No*: / Click here to enter text.
Home address*: / Click here to enter text. / Date of birth*
Click here to enter a date.
Sex*: M ☐ F ☐
Work address*: / Click here to enter text. / Email address*
Click here to enter text.
Telephone/Mobile number*
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Is the employee absent from work? * / Choose an item. / Job Title: / Click here to enter text.
Reason leading to referral*: / Choose an item.
Please provide any dates or periods the employee will NOT be able to attend an appointment: / Click here to enter text.
Type Of Health Surveillance Referred For
Hand Arm Vibration Syndrome (HAVS) / ☐ / Respiratory Function / ☐
Audiometry (Hearing) / ☐ / Skin Assessment / ☐
Lung Function Test / ☐ / Private Hire Car Medical / ☐
LGV/PVC / ☐ / Forklift Truck Driver Medical / ☐
Other (please specify) Click here to enter text.
LINE MANAGER’S REFERRAL
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.
Click here to enter text.
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) Click here to enter text.
I understand that this referral will become part of the OH record and will be disclosed to the employee on request
Manager’s Signature: / Click here to enter text. / Date*: / Click here to enter a date.

PLEASE EMAIL COMPLETED FORM TO WLCOH@OPTIMAHEALTH.CO.UK

Please inform the employee that it is the Councils position that failure to keep the appointment without prior notification may result in the employee’s non-attendance being reported to their line manager, and possible disciplinary action being taken against the employee

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