Get in touch
Please ensure this form is completed fully to assist the Occupational Health Advisor / Physician in providing you with a comprehensive report.
Name*
Company*
Telephone Number*
Fax Number
Mobile Number
Email*
Position*
Address*
Date of Birth*
Job Title*
Department*
Location / Post / Site
Full Time / Part Time? *
Length of time in current position*
Home Telephone*
Daytime Telephone*
Upload Sickness Print
Are there any specific requirements needed to assist in this assessment (i.e. interpreter, advocate) Yes / No : If yes please specify
Please describe duties of the position (or upload copy of job description)
Upload Job Description
Reason for Referral*
Please provide details of current problem (How is this affecting their ability to work?)
How long has the problem been present?*
What remedial action have you taken?
What specific questions do you want answered?
Is the medical problem caused or made worse by work?Is the employee fit to perform their current duties?Is the employee’s medical condition currently or in future likely to fall under the Equality Act 2010 (Disability Related)Is there an Underlying Condition?Does the employee require any modification to his work? If so please specify required modifications and for how long?Will further medical information be required prior to outcome of the assessment?Please indicate if know when this employee is likely to return to work date?Will a review appointment with OHS be required? If so please state the date.Will a phased return be necessary for this employee? If so please specify the return to work programme.Prognosis of regular attendance in the future.
“Please add any other specific question/s you like answered by the Occupational Health advisor or Physician following this consultation
I confirm that the reason for referral has been fully explained to the employee. Referring Manager
Date*
