Infinity occupational health referral

MANAGEMENT REFERRAL FORM The referral must be discussed with the member of staff and his/her agreement obtained before submission.

Please type form if possible

DETAILS OF REFERRING MANAGER (name and address for reporting purposes): Name of manager making the referral: Name of Company

Position:

Address:

Office Tel:

Mobile:

Email:

STAFF MEMBER – PERSONAL DETAILS: Title:

First Name/s:

Date of Birth:

Home Address:

Surname:

Tel. number: Email: Job Title:

Usual hours of work:

Length of Service:

Work Address: Work pattern: Click relevant ☐Full time ☐Part time ☐Job Share ☐Relief ☐Night Work ☐Other: box (please specify) Further details Please provide a short summary of work activity here – e.g. what activities in a typical day?

THE REASON FOR THE REFERRAL IS AS FOLLOWS:

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CL I C K R E L E V A N T BO X E S

MANAGEMENT REFERRAL FORM A

Five episodes of absence in the last 12 months

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B

Signed off sick for a continuous period of 21 days or more in 1 episode

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C

Experienced second absence in rolling 12 month period for a Mental Health condition

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D

Experienced second absence in rolling 12 month period for Musculoskeletal condition

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E

Absent on the grounds of ill health and is subject to formal disciplinary proceedings

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F

Other – please give details

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Please give a description of the issue that has prompted this referral:

Is the employee currently absent from work?

☐NO ☐ YES

Please tell us the 1st date of absence:

Previous sickness absence and dates

Additional/supporting information: Are there any possible adjustments which you as a manager feel may help in the situation?

Are there any parts of the role which you have safety concerns about?

QUESTIONS YOU WOULD LIKE ANSWERED

CLICK RELEVANT BOX/S .

Is the employee fit for normal hours and duties required by his/her post?

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When will they be able to return to work/return to normal hours/duties?

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Is there an underlying medical condition affecting their ability to work?

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How does this condition affect the employee at present?

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Are they having appropriate treatment, will it aid their recovery and if so when?

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Is this employee likely to be able to provide regular and effective service in the future?

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In your view, is the employee likely to be covered under the disability provision of the Equality Act 2010?

Advice with regard to possible adjustment(s) and support which the employer could consider.

Other – maximum 10 questions permitted please provide detail below.

Any additional questions will be chargeable.

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MANAGEMENT REFERRAL FORM

Please return all documents to us via e-mail Infinity Occ Health Referral Email or by post to: Infinity Occupational Health, Princess House, Princess Way, Swansea, SA1 3LW Should you have any queries or require additional information, please contact us on (01792) 482481

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