OCCUPATIONAL HEALTH REFERRAL OCCUPATION HEALTH REFERRAL Employee's full nameEmployee's address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Work locationDate of birth Home PhoneMobile PhoneWork PhoneEmail Job / Job TitleWork Demands/Hours per day eg: Lifting, Bending, Standing, Computer work, Driving, Telephone work etc.Date they first went off sick Reason (on self-cert or GP cert) for absenceHow long (e.g. 4 weeks) is their current certificate for, and when does it expireDetailed history of absence – Please give all datesReason for referralConsentI have discussed this referral with the employee named above and they have consented to attend an OH assessment. Verbal consent Consent in writing InformationSigned by ManagerDate of Referral Name, email address and phone number of manager making the referralPlease confirm what information you are seeking from this referral/what questions you would like answered. Please ensure that full information has been provided and include a job description if possibleSuggested questions you like to have answeredPlease tick as many questions as appropriate Can you confirm the current health conditions the Employee is suffering with. What impact does this health condition(s) have on the Employee that we need to be aware of in relation to their duties? What impact is this likely to have on the Employee’s future attendance at work? What medication and / or treatment is the Employee currently receiving? Are there any specific measures, reasonable adjustments and / or restrictions we should consider making to accommodate the Employee’s condition at work? For example, hours of work, pattern of work, amount of additional hours offered etc? How long term in your opinion is this condition likely to continue to affect the Employee? i.e. is this a chronic and / or permanent condition and therefore any reasonable adjustments you may recommend are likely to be permanent, or, is this a temporary situation that with appropriate treatment and support the Employee may make a full recovery? Any approximate timeframes you may be able to suggest will be helpful. Can you confirm if the Employee’s condition should be considered a disability in relation to the Equality act 2010? In your opinion, should the Employee’s sickness absence trigger points in line with Company policy be adjusted? Is there any further support we should be offering the Employee or further information regarding their condition we should be aware of? Is there anything else that the Employee can do to support her own health wellbeing?
