Policy and Procedure on Dealing with Ill Health
Responsible Directorate: Responsible Director:
Human Resources and Organisational Development Sue Ellis
16 December 2009 (Trust Board)
Kirklees Partnership Forum
NICE GUIDANCE Once NICE guidance is published, health professionals are expected to take it fully into account when exercising their clinical judgment. However, NICE guidance does not override the individual responsibility of health professionals to make appropriate decisions according to the circumstances of the individual patient in consultation with the patient and/or their guardian or carer.
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Version Control Current versions of all policies can be found on NHS Kirklees internet and intranet. If printing a document, please check internet/intranet for most up-to-date version. Document Title: Document number: Author: Contributors: Version: Date of Production: Review date: Postholder responsible for revision: Primary Circulation List: Web address: Restrictions:
Policy & Procedure on dealing with ill health V2 Debra Booth NHS Calderdale/Kirklees Partnership Forum 2 July 2009 July 2012 Debra Booth, HR Officer All Staff Internet, Employment Policies & Procedures
Standard for Better Health Map Domain: Core Standard Reference: Performance Indicators:
1. 2. 3.
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Section 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. Appendices 1 2 3 A B
Introduction Purpose of Guidance Sickness absence categories Sickness Absence reporting General Principles Dealing with Long Term Sickness Absence Dealing with Frequent sickness absence Dealing with Frequent Sickness with unconnected medical conditions Occupational health Qualifying for Occupational sick pay Witholding Occupational sick pay Medical Suspension Industrial Injuries Disability Discrimination Act Communicating Decisions Achievement of improved attendance Responsibility of employee, line manager and HR Review of Procedure
Employee Statement of sickness/return to work interview Employees Phased return to work agreement Guidance for arranging formal meetings OH In service Management Referral Form Equality Impact Assessment Tool
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Page 5 6 6 6/7 7/8 8/9 10 11/12 13 13 14 14 14 15 15 15 16 17
18-20 21 23 24-26 27
DEALING WITH ILL HEALTH POLICY
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Introduction The NHS Kirklees (The Organisation) recognises that staff are the most important asset in service provision. If their health and welfare affect attendance at work then there will be an effect on the Organisation ability to provide the required services. This policy should be read alongside the organisational procedure on the management of ill health. High rates of absenteeism are costly not only from an economic point of view but also because of the effects on morale for other staff and the potential loss of continuity of patient care. Although it is acknowledged that illness can necessitate time off work, it is vital that all staff remain conscientious and committed towards achieving and maintaining highly satisfactory levels of attendance.
Policy Statement It is the policy of the Organisation that a consistent, fair and supportive approach is taken to the management of sickness absence from staff. It is the policy of the Organisation that staff will be treated consistently and in accordance with fair and reasonable employment practice. It is the policy of the Organisation that the procedure followed will adhere to current legislation and best employment practice particularly noting discrimination law and our duties regarding disability discrimination as outlined in the Disability Discrimination Act.
Review of Policy This policy will be reviewed within 3 years following the approval of the policy.
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The Procedure on the Handling of Ill Health 1.
Introduction The NHS Kirklees (The Organisation) recognises that staff are the most important asset in service provision. If their health and welfare affect attendance at work then there will be an affect on the Organisation ability to provide the required services.
Purpose of guidance It is the purpose of this procedure and management guidance that a consistent approach will be maintained to addressing ill health within the Organisation and will ensure that problems are dealt with in accordance with fair and reasonable employment practice. This policy aims to provide advice and guidance for the management of both long term and short tem absence.
Sickness absence 3.1
Sickness absence issues fall into three categories:a) A protracted period of absence due to ill health or other incapacity; b) Intermittent absence as a result of an underlying medical condition; c) Intermittent sickness as a result of unconnected medical conditions.
Non-medical reasons for absence Absence that is claimed as sickness absence and is subsequently believed not to be due to ill health may be considered as misconduct and dealt with in accordance with the disciplinary procedure.
Sickness absence reporting An employee must report their absence due to sickness as soon as reasonably possible or normally within 2 or 4 hours of their normal or rota start time, depending on their contractual obligation and departmental policy. Where possible an indication of the length of absence expected should be given, although it is recognised it may be difficult to provide such information with any accuracy. However, if an estimated length of absence is given and it is necessary for that period to be extended, the employee must maintain
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either verbal or written contact with their line manager, which may or may not include the submission of medical certificates. Line manager to complete current absence on employee statement of sickness/return to work â€“ Appendix 1 attached. On their return to work an interview is to be held with the line manager and member of staff. Section 2 of appendix 1 and copy of form forwarded to local HR representative. Absences of more than 3 days and up to 7 days including weekends and bank holidays will require the member of staff to complete a self-certification form. These forms are available at www.hmrc.gov/uk/forms/sc2.pdf If the absence lasts more that 7 calendar days, the member of staff is required to produce a medical certificate. This should be received by the manager by the 8th day of absence and staff are advised to visit their doctor as soon as possible to ensure that a doctorâ€™s certificate is produced on time. Staff must throughout any period of absence, maintain contact with their manager to inform them of when they anticipate returning to work or if another period of absence is expected. Dependant on the period of absence, the line manager will maintain contact on a regular basis, including telephone and home visits prior to arrangement. Staff wishing to return to work before their sick note expires is required to produce a certificate from their doctor which certifies that they are fit for work. Where a member of staff alleges that their absence is due to an injury or disease attributed to NHS employment, must be notified to your line manager and recorded on the Organisation Accident/Incident reporting system. If a member of staff falls sick whilst on annual leave, the organisation will convert this to sick leave, so long as they can provide medical certification of the sickness and have followed normal sickness reporting procedures. Failure to report sick, produce sick notes or attend occupational health in accordance with contractual obligations and without acceptable reasons continue to be classed as issues of misconduct and should be dealt with via the disciplinary procedure. Failure to comply with any of the above could result in the absence being regarded as unauthorised and will also result in loss of pay.. 5.
Key Objectives for Managers Handling Problems of Sickness Absence a) Handle long term sickness sensitively.
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b) Deal with trends of frequent instances of short term sickness absence fairly and promptly but again with sensitivity. c) Be objective in ensuring that employees with similar sickness absence problems and levels receive the same approach. This is to achieve consistency within the Organisation and so give employee’s confidence that whatever status held or wherever one works procedures will be applied fairly at all times. 6.
Dealing with Long Term Sickness Absence (LTC is defined as any absence of 4 weeks or more) 6.1
Employees with long term certified absence through ill health will be treated sympathetically and the following procedure should be adopted.
Contact should be maintained between the manager and employee. This is to help both parties, the employee will be able to raise any particular concerns with the manager and in turn the manager will be able to establish the likely duration of absence which will enable more informed decisions to be made when planning services and the future needs of the employee.
6.3.1. A formal review of an employee’s long term sickness absence must take place, at the latest, at the 3 month stage or when full sick pay is due to expire if this is earlier. The review meeting should involve the line manager and a human resource representative. The manager should consider an occupational health referral. The employee may be accompanied by a trade union representative or a friend. 6.3.2. The purpose of this is to give joint consideration to varied options such as:•
Possibility of return to work in the existing role and when;
Possibility of alternative employment if appropriate.
Possibility of reasonable adjustments subject to the Disability Discrimination Act.
Premature retirement on the ground of ill health; or
Termination of contract (dismissal) on the grounds of medical capability as a last resort.
6.3.3 As part of the review(s) a number, or all, of the factors may be considered.
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Flexible working arrangements will always be considered after taking in to account occupational health advice on the duties of which the employee is capable.
Where an employee is fit to resume work after a long absence then options such as reduced/amended duties, and shorter or more flexible hours should be fully explored and considered on a short term ‘easing in basis’ in parallel with the demands of the service.
If the employee is unable to return to their normal work on their contracted hours for a longer time period then consideration will be given to them returning on temporarily reduced hours for up to 3 months. The effect upon the service as well as other members of staff will be considered. Any temporary arrangement will be reviewed on a regular basis. At the end of this time consideration needs to be given as to whether they can return to their ‘substantive’ hour’s contract, if not then the reduced hours should be their new permanent contracted hours.
6.3.4 It is important that the employee is kept fully informed, in writing if employment or pay is at risk. Normally this would be addressed at the review meeting. The salient points of the review meeting should be recorded, detailed to the employee and a copy maintained on file. 6.3.5 Provided that written consent is given, regular advice may be sought from the employee’s GP by the occupational health department. In the event of any employee refusing to give consent then the employee must be advised that a decision will have to be taken on the basis of information available with dismissal as a possible consequence. 6.3.6 If there is concern or dispute regarding the nature of any injury or illness then occupational health should arrange an independent medical examination. It is a contractual obligation to undergo a medical examination and failure to do so may result in management stopping an employee’s occupational sick pay and making a decision on the employees continued employment based upon the information available and should be treated as an issue of misconduct. 6.3.7 Dismissal on the grounds of ill health should only be considered when all the available facts and reports have been obtained. Dismissal should always be preceded by formal evidence of the employee having been previously advised of this as a potential outcome. Managers should take the advice of the human resource manager on any potential implications from the Disability Discrimination Act prior to dismissal.
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6.3.8 When it is decided to dismiss, the normal condition of giving notice will apply even though, in practice, the employee will be unable to work the same. In such circumstances the employee should receive pay throughout the notice period or pay in lieu of notice. 6.3.9 It should be noted that decisions to dismiss on the grounds of ill health are managerial decisions and are based on reasons of capability to do the work. The line manager must initiate discussion regarding potential cases with a human resource manager who will take responsibility for ensuring that fair and correct action is taken. 6.4 Phased return to work from long term sickness 6.4.1 If a member of staff has been absent for some time, the Organisation has the option to facilitate a member of staffâ€™s return to work by offering a phased return to their own job or another role on a temporary basis. In circumstances where an individual would otherwise remain on sick leave, a phased return may be agreed during which time the individual may work reduced hours and still receive their normal pay and the organisation will contribute the equivalent of up to two weeks pay to support this as part of an agreed return to work plan. Managers should seek advice from HR & Occupational Health and together with the member of staff arrange a pre-return meeting to establish a return to work support plan. In exceptional circumstances a longer period of phased return may be agreed but will only be subject to the equivalent of up to 2 weeks pay. Other arrangements therefore, need to take account of flexible working and annual leave if required. 6.4.2 This must be agreed in advance and is at managers discretion. An employeeâ€™s phased return to work agreement should be completed by the line manager (Appendix 2). 6.5
Accrual of holiday entitlement whilst on sick leave
6.5.1 Carry over of annual leave after sickness to be discussed with HR. 7.
Dealing with frequent absence for the same underlying medical condition(s)
When there are 3 separate instances of sickness absence over a 6 month rolling period for the same condition, the line manager should investigate the circumstances via a discussion meeting. This is considered to be a normal meeting a line manager would have with one of his/her staff and as such it is not expected for a member of staff to have his/her representative at a meeting at this informal stage. Occupational health advice would normally be sought to inform the meeting.
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Consideration should be given to whether the duties of the post are contributing to the absences and, if so, what steps can be taken to resolve this.
The purpose of the meeting will be to establish the number of periods of ill health and the duration of each absence. It will also establish the reasons and consider/explore any factors contributing to the absences. It will also outline the consequences as the individuals attendance is considered unsatisfactory. The process followed will be as detailed under Formal Discussion (section 8.2) and thereafter.
With absences for the same underlying medical condition managers should consider the requirements of the Disability Discrimination Act.
Dealing with frequent absence for sickness with unconnected medical conditions
Where the number of occasions of sickness absence reaches 3 separate instances within a rolling 6 month period, the line manager should investigate the circumstances via a discussion meeting. Occupational health advice would normally be sought to inform the meeting. The purpose of the meeting will be to establish the reasons, consider and explore any factors contributing to the absences. It will also outline the consequences as the individuals attendance is considered unsatisfactory. The process followed will be as detailed under Formal Discussion (section 8.2). Where following the attendance meeting, if the required improvements in attendance have not been achieved, it may be necessary to refer the matter to a senior manager
First Stage Formal Meeting In line with the above and following earlier failed attempts to ‘nip problems in the bud’, a formal discussion interview should take place between the line/senior manager and employee. The employee will be given a minimum of 5 working days notice, the right to be accompanied. A representative of HR will accompany the line manager. The interview should cover:•
Management concerns regarding genuine inability to achieve a satisfactory standard of attendance.
A need to achieve improvement combined with further offers of help eg working environment, amended duties where practicable etc.
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A period of performance monitoring with a definitive review date (It is recommended that this does not exceed 3 months in the first instance). If immediate improvement is not achieved then further action should be considered within the 3 month period.
The potential consequences of failing to achieve improvement.
The possibility of alternative employment or job redesign (if felt appropriate)
The salient points of the discussion should be detailed in writing to the employee and a copy retained on the personal file for 12 months. Note: advice should be sought from occupational health to facilitate an effective discussion. 8.3
Second Stage Formal Meeting If the formal discussion fails to have the desired effect then a second stage formal meeting should be convened focusing attention upon:• Management’s increasing concerns regarding failure to achieve a satisfactory standard of attendance. • A period of attendance monitoring with a definitive review date (It is recommended that this does not exceed 3 months in the first instance). If immediate improvement is not achieved then further action should be considered within the 3 month period. •
An explanation of the extreme seriousness of the situation and that this represents the last opportunity to achieve improvement and maintain a satisfactory level of attendance and the potential consequences of failing to achieve improvement.
The possibility of alternative employment or job redesign (if felt appropriate).
The results of this meeting should be confirmed in writing to the employee with a copy on the personal file for 2 years. Note: Updated advice should be obtained from occupational health prior to the meeting. 8.4
Final Formal Meeting When all procedural steps have failed then a decision to dismiss on the grounds of capability has to be taken. However, suitable alternative employment could be considered as an alternative. This potential course of action should be discussed with the Assistant Director of human resources Page 12 of 27
and a formal meeting convened. Right to appeal to be made in writing to the Assistant Director of Human Resources within 3 weeks of the date of the letter confirming the decision to dismiss. APPENDIX 3 REFERS 9.
Occupational Health Referrals In response to employee referrals the occupational health department will supply the following information to the manager concerned:•
The likely date of return to work.
The likely terms of the disability.
Specific limitation which should be taken in to account in redeploying the employee.
Underlying medical reasons which may contribute to an unsatisfactory attendance record.
The likelihood of the employee maintaining regular and efficient service in the future.
For reasons of confidentiality, consistency and effectiveness any medical assessments will be sought through the occupational health department, not an individual’s GP. The occupational health department will contact the GP or consultant if necessary with the member of staff’s agreement under the Access to Medical Records Act 1998. On receipt of the medical information the Line Manager with support from the HR Business Partner/Adviser can make decisions on future actions in conjunction with the member of staff and their representative. All reasonable efforts will be made to ensure up to date medical evidence is available before any decision is made. 10.
Qualifying for Occupational Sick Pay The Scheme is intended to supplement Statutory Sick Pay and Incapacity Benefit to maintain normal pay during defined periods of absence. Basic entitlement, as defined by Agenda for Change is as follows for organisation staff.
Period of Continuous Service During first year of service
Period of Sickness Allowance One month full pay, two month’s half pay
During second year of service
Two months full pay, two months half pay
During third year of service
Four months full pay, four months half pay Page 13 of 27
During fourth and fifth years of service
Five months full pay, five months half pay
After completing five years of service
Six months full pay, six months half pay
Withholding Occupational Sick Pay 11.1
If staff do not comply with reporting and certification procedures appropriate deduction of pay will be made immediately. Staff who have a good reason for not complying should tell their line manager and, if appropriate (in exceptional circumstances) pay will be reinstated.
Benefits may be withheld at the Organisation discretion, in cases where the member of staff was working for someone else in their own time, or staff who put themselves at undue risk e.g. dangerous sports injuries.
Benefits may be withheld if the Organisation believes that the member of staff is not genuinely sick.
Any claims identified as being fraudulent will be referred to the Counter Fraud Office in the first instance and may be dealt with under the Organisationâ€™s Disciplinary Procedure.
Medical Suspension 12.1
It may be necessary to suspend staff from work if:
In the opinion of occupational health the member of staff is unfit to work, but is declaring themselves fit or is being declared fit by their own doctor.
If individual staff are at work but are deemed a risk to themselves or to others because of their health, they may be medically suspended. Medical suspension is not dependant on the Occupational Health Department.
If necessary aids or adaptionâ€™s are not operating or in place.
Any medical suspension will be on full pay, it is not a disciplinary suspension.
Any such case must be discussed with Human Resources.
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If an employee suffers an injury at work, including work related stress, they should complete an incident form which is available in hard copy or on the intranet under Risk Management/Incident reporting. Once the risk is notified and if it fits the criteria for reporting under RIDDOR the safety manager will complete the on line form on the HSE website.
If sickness absence occurs as a result of the injury then a sickness Absence Notification form must be completed highlighting that an injury has occurred.
The Department of Social Security should also be informed by the employee because in the event of long term sickness absence, industrial injury benefits may be payable.
Timesheets should indicate that the reason for absence is due to an injury at work.
Employees and Mangers should contact the Human Resources or payroll for further information on Industrial Injury benefits which may be payable under the NHS Injury Benefit Scheme Regulations for England and Wales. Further information can also be found on www.pensionsagency.nhs.uk.
Disability Discrimination Act (DDA) 14.1
Communicating decisions 15.1
During all stages of this procedure line managers and human resource managers should be aware of the particular requirements of the DDA, particularly in relation to reasonable adjustments to the job and workplace and to consideration of alternative employment.
Whilst accepting that the issue of warnings or cautions does not fit readily with many aspects of managing sickness absence, it is equally important that in communicating decisions/outcomes of formal meetings that the member of staff is fully aware of the potential consequences as outlined and/or the increasing vulnerability of employment if an improvement in attendance is not made and sustained. Outcomes of meetings will always be confirmed in writing.
Achievement of improved attendance linked with formal meetings 16.1 It is important that employees who at the review stage have demonstrated the desired improvement are thanked for their efforts and advised that the improvement must be sustained. However, to avoid relapses the record of formal action will remain on personal files for the undermentioned periods of time and will continue to be valid for future use.
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First Stage Second Stage
12 months 2 years
16.2 If attendance remains satisfactory throughout the above timescales then the employee must be advised that the warning has expired and so is invalid for future use. 17.
Responsibility of the Employee
It is the employee’s responsibility to attend for work on a regular basis and to ensure that they are fit to attend work.
It is the employee’s responsibility to submit self certificates and medical certificates in a timely manner as required.
It is the employee’s responsibility to ensure they inform their line manager at the earliest possible opportunity if they are unfit to attend for work, outlining the reasons for their absence and a likely duration of their absence and any work related issues that may need addressing during the course of their absence.
Attend formal meetings and Occupational Health for assessment as requested.
Responsibility of the Line Manager •
Advise employees of procedure to be followed regarding the notification of absence and production of certification.
Advise employees that sickness absence will be closely monitored. On the first day of sickness manager completes an Employee Statement of Sickness/Return to Work Sickness Form showing commencement date and reason upon return to work for manager to complete section.
Maintain and monitor records including details of duration and reason. Full confidentiality must be maintained at all times.
Identify trends that are developing and discuss with a human resource representative resulting concerns.
Immediately on return to work discuss reasons for sickness absence with employee and record the discussion. This is in the interest of fairness (for employees) to avoid future disputes over attendance record/level of absence.
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Submit a monthly return of sickness absence to the payroll department with a copy to the human resources department.
It is the line manager’s responsibility for establishing the formal and informal meetings.
Refer the employee to occupational health using the appropriate referral form (Appendix 1) if the employee has:4 consecutive weeks sickness (if the employee is for example an in-patient in hospital or convalescing after a major operation then advising occupational health is sufficient). OR 3 separate instances of short term sickness within any 6 month rolling period.
The line manager should take the lead role in addressing sickness absence problems through monitoring records and receiving sick notes. 17.3
Responsibilities of Human Resources •
To maintain the Organisation absence monitoring system and advise of levels.
To support line managers in interviews, home visits and meetings as necessary.
To assist and advise the line manager in making decisions on how to effectively deal with short and long term sickness absence problems.
It is the responsibility of human resources to ensure circulation and adherence of this policy and procedure.
It is the responsibility of human resources to support line managers in dealing with all sickness problems within their remit.
Human Resources will support line managers at formal meetings and provide guidance on the policy and current employment law.
Review of Procedure This procedure will be reviewed within 3 years following approval.
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APPENDIX 1 Employee’s Statement of Sickness/Return to Work Interview
NB: Completion of this form must be commenced on the first day of sickness by the designated person and completed by the employee and Line Manager/Supervisor on the first day back to work Title:
Job Title: Department: Work Base:
Contracted Hours a Week:
Name of the person taking the call: Brief Details of Sickness:
Dates of Sickness: Date of 1st Day of Expected date of return (if Sickness: known): * If an estimated return date is given, please include Actual Date of return: details of subsequent contacts in the next box Did the employee leave early? Yes No If Yes at what time did the (Therefore not recorded on the sickness return) employee leave work? Contact information: (give brief details of any contacts with employee including dates and times)
Was the sickness cause by an accident at work or an industrial disease? If ’yes’, have you completed an incident form?
http://nww.kirklees.nhs.uk/risk-management/ (Please note you may be able to claim Industrial Injuries Disablement Benefit. Contact your local Social Security Office to obtain a form)
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Line Managers Signature:
Date: Please forward a copy of this completed form, to your local HR representative
Return to Work Interview
NB: Completion of this form must be commenced on the first day of sickness by the designated person and completed by the employee and Line Manager/Supervisor on the first day back to work Date of interview
Interview Details: (continue on a separate sheet if necessary) What was the reason for your absence from work? Was your absence work related? Was your absence a recurrence of a previous illness / Absence? Did you visit your GP? Yes No If yes what did they say How are you feeling now? Do you feel you have fully recovered from your illness to return to work? Do you think there is anything else the ORGANISATI ON can do to support you further? Number of absences in last 12 months: Please note that where there are 3 separate instances of sickness absence over a 6 month rolling period then the Organisation Policy and Procedure on Dealing with Ill Health should be followed
Is a follow up required? If â€™yesâ€™
Monitor & Review Formal Review with HR Undertake Risk Assessment Restricted Duties Adjustment to hours/or work pattern - record agreed options
Yes No Training updates required Occupational Health Referral Medical Certification Required Unauthorised absence - Disciplinary
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Signature of employee (a copy of this maybe given to the employee) Employees Signature: Line Managers Signature:
Please forward a copy of this completed form, to your local HR representative Our aim as an employer is to support staff, identify any workplace issues and apply procedures fairy and consistently.
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APPENDIX 2 Employeeâ€™s Phased Return to Work Agreement
NB: This form should be completed by the line manager and employee at a pre-return to work meeting Surname: First Name(s):
Contracted Hours a Week: Meeting Details: (continue on a separate sheet if necessary) Week Week Number of Days Agreed Days Number of Days or Commencing to be worked? & Times? Hours Annual Leave (Date) Using One
Date of Meeting:
Two Three Four Five Six Formal Review Date: (Informal reviews must take place at least weekly between line manager and employee) Additional Comments/feedback from occupational health/GP: Other Comments: Signature of employee (a copy of this should be given to the employee) Employees Date: Signature:
Line Managers Signature:
Please forward a copy of this completed form, to your local HR representative Our aim as an employer is to support staff, identify any workplace issues and apply procedures fairy and consistently
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Appendix 3 Guidance for arranging formal meetings •
The employees must be advised in writing at least 5 working days in advance.
A short but concise description of the attendance problem must be contained within the letter.
The letter must inform the employee of the line manager conducting the meeting and the human resource representative assisting.
A human resource representative must be present at all formal meetings. The employee must be advised of the right to be accompanied by a trade union representative or friend not acting in a legal capacity. All decisions must be confirmed in writing to the employee with a copy retained on the personal file. a. Authority to dismiss A decision to dismiss can only be taken by a director with the delegated authority of the ORGANISATION chief executive. This as stated earlier, is following discussion with the assistant director of human resources. The manager next in line to the manager who issued the warning will hear any appeal accompanied by a different human resource representative. b. In the event of dissatisfaction Employees dissatisfied with the action proposed at any stage, other than dismissal, will have the right to meet with the manager next in line to the manager involved in the formal stages. This will provide the opportunity for discussion and possible arbitration. The employee will be able to invite a trade union representative or friend not acting in a legal capacity to the meeting. There will be a right to appeal against dismissal, notice of which is to be given to the Assistant Director of human resources within 3 weeks of the letter confirming dismissal.
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Occupational Health Services In Service Management Referral form KIRKLEES AND CALDERDALE ORGANISATIONs
Occupational Health Services Pinderfields General Hospital Aberford Road Wakefield WF1 4DG Tel: 01924 212467
HR Department: ………………………………………………………….Name:………………………………...
PRIVATE AND CONFIDENTIAL Head of Department: (and if different referring person) Department/Division Employees Name:
Address of employee:
Date of Birth of employee: Employees Telephone No:
(home/mobile and work)
Please give clear details, below, of the reasons for this referral. Additional information may be attached to this form if you wish. Please include the job elements you are specifically concerned about Section A: to be completed by the referring person If you are worried about your employee’s physical well being, you should provide specific details of the issues causing concern. These should include a description of any physical disabilities, inability to undertake certain duties/activities and details of any injury sustained and whether they are home or work related etc.
If you are worried about your employee’s psychological/mental well being, you should provide specific details of the issues causing concern. These should include a description of any inappropriate behaviour, alterations in behaviour, problems between the employee and colleagues and/or any known psychiatric ill health.
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Section B: to be completed by the referring person What action has been taken to try and accommodate your employeeâ€™s health problems? Please include details of any risk assessments. Re-deployment, alterations to job elements, graduated return to work, attendance management etc:
Section C: to be completed by the referring person. Is this person Currently off sick (yes or no)
On full pay (yes or no)
On Half Pay (yes or no)
Out of pay (yes or no)
Superannuated (yes or no)
Suspended give reason eg. Medical/Disciplinary
Section D: to be completed by the referring person.
Signature of the referring person
Signature:_____________________________________________________Date:____________________ Designation:___________________________________________________ Dept:____________________
Report to be sent to: Please print Name:
Address: _________________________________________________ _________________________________________________ Copy to be sent to Human Resources: Name: _________________________________________________ Address: _________________________________________________ _________________________________________________ Section E: to be completed by the referring person. (tick where appropriate)? Attached the job description
Attached any sickness absence details
Supplied additional information
Completed Sections A to E
Discussed the contents of this referral with the employee concerned
Signed section D and ensured that the employee has signed Section F
Section E continued, Managers questions: what do you want to know? Is there an underlying medical condition? Is he/she fit to undertake their duties? When will he/she be fit to undertake his/her
In your opinion would this person be covered by
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the Disability Discrimination Act?
Are there any adjustments you recommend?
Do you recommend re deployment?
Is he/she likely to be able to give reliable and effective service/attendance in the future?
Is there any additional help or support you recommend?
Would this person be suitable for consideration for early retirement on the grounds of ill health?
Section G: to be signed by the EMPLOYEE (after they have read this completed form)
I have read and have had the opportunity to discuss the comments/and/or read the attachments made in this referral. I understand the purpose of this referral to the Occupational Health Service and I am happy to attend. This form should now be sent to the address above.
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B. Equality Impact Assessment Tool To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. Insert Name of Policy / Procedure Yes/No 1.
Does the policy/guidance affect one group less or more favourably than another on the basis of: • Race
• Ethnic origins (including gypsies and travellers)
• Religion or belief
• Sexual orientation including lesbian, gay and bisexual people
• Disability - learning disabilities, physical disability, sensory impairment and mental health problems
Is there any evidence that some groups are affected differently?
If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?
Is the impact of the policy/guidance likely to be negative?
If so can the impact be avoided?
What alternatives are there to achieving the policy/guidance without the impact?
Can we reduce the impact by taking different action?
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The policy contains explicit statements regarding our responsibilities as an employer to support people who are newly disabled or covered by the disability discrimination act. This is with a view to ensuring appropriate support is provided.