Referral Form

Referring Manager

Referring Person’s Name:

Referral Date:

Referring Company:

Department:

Referrer’s Contact Number:

Referrer’s Email:

HR Contact

HR Contact Name:

Contact Number:

Contact Email:

Employee Details

Employee Name:

Address:

Postcode:

Date of Birth:

Contact Number (home):

Contact Number (mobile):

Contact Email:

Employee Job Title:

Finance

Purchase Order No (If Required):

Finance/Accounts Contact Name:

Finance/Accounts Contact Number:

Can the referrer confirm that the employee has been informed of the referral and the purpose of this?

Please tick relevant box:

Yes No

Date Employee was Informed:

Please state if the employee has any accessibility needs that need to be considered when arranging the appointment

(e.g. wheelchair access needed)

Employee Work Pattern:

Employee’s Role:

Please provide a very brief description of the employee's duties: *

Purpose of Referral: (Please tick the most relevant box) *

Prolonged sickness and absence Recurrent short term sickness or absences Concerns about work performance and/or fitness for work Advice on potential work adaptations Health surveillance processes, e.g. regular screening related to workplace hazards Occupational exposure hazard concerns Advice following workplace illness/injury Fitness to attend disciplinary investigations or hearing Advice related to substance misuse

Attendance:

Please list the employee’s attendance record over the past 12 months, including the dates of any sickness absence in the last 12 months.

If the employee is currently absent, please state first date of absence:

What category best describes the reason for the employee's absence? *

Standard Questions: *

Please read and tick the appropriate boxes below for which you would like an occupational health opinion/response on:

Is the employee currently fit to undertake their role? If not, in your clinical judgement, when are they likely to be fit to return to work (either fully or with adjustments)? Are there any work-related or workplace factors that may have contributed to, exacerbated, or impacted upon the employee’s current medical condition? Are there any recommendations / adjustments (temporary or permanent) that management should consider to support the employee in attending or returning to work? In your opinion, is the employee likely to have a condition that may meet the definition of a disability under the Equality Act 2010? None of the above applies (I will provide details in the additional questions)

Additional Questions:

This section is optional. If you have additional questions, please include these here. Please note that additional questions may require a longer assessment and therefore may increase the cost of the referral.

Additional question 1 (please input here):

Additional question 2 (please input here):

Additional question 3 (please input here):

Additional question 4 (please input here):

Additional Comments:

If you have any further comments, please add them below, including anything that may be helpful for OH to know or any additional context you would like to share.

How did you hear about us? *

Please tick one or more:

Google / search engine LinkedIn Instagram Recommended by (please state who) Other (please state) Please tick this box if you are happy for us to retain your contact information for use to send periodic marketing materials

Recommended by (please state who)

Please state how did you hear about us?

Cancellation or Non-Attendance

2-5 clear working days’ notice before date of appointment:	Half Fee
Cancellation within the 2 clear working days before appointment day:	Full Fee

Elementior Form

Nation Occupational Health Ltd - Referral Form

Referring Manager

HR Contact

Employee Details

Finance

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