Management Referral Form | Gipping Occupational Health

Company Details
Company Name*
Referring Manager*
Work Location*
Telephone Number & Extension*
Email Address*
(for sending copy of clinical report to)
HR Representative*
Telephone Number & Extension*
Email Address*
(for sending copy of clinical report to)
Would it be helpful for the OH Advisor to discuss this referral with the immediate Line Manager?*
(If yes, make sure the contact details are completed and that the person will be expecting a call)
- Yes
- No
Does your organisation have an Employee Assistance Programme (EAP)?
- Yes
- No
Employee Details
Employee Name*
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City County / State / Region Post Code Country
Home Phone Number*
Mobile Phone Number
Email*
(for sending copy of clinical report to)
Employee Occupation/Job
Start Date
DD slash MM slash YYYY
Dept / Area / Location
Hours of Work
- Select All
- Full Time
- Part Time
- Days
- Shifts
- Temp/Agency
Does the reason for referral affect:
- Select All
- Attendance
- Performance
- Conduct
- Safety Standards
Are absences covered by :
- Med 3 Fit Note
- Self-Certificate
- Unauthorised
Is disciplinary action or other management intervention being considered or already taken?
- Yes
- No
Reason for Referral
Referring Manager/HR please tick the boxes below as appropriate to indicate the reason for referral.
- Concern about frequent short term absence
- Concern about long and continuous period(s) of absence
- Advice about return to work after long term illness, injury or surgery
- Concern about health in relation to an employee’s ability to carry out their role
- The employee has declared a medical problem; advice is required about the effect of this on ability to work
- Advice regarding information given in a ‘fit note’ or return to work plan and how to interpret this
- Concern that a member of staff may have an infectious or contagious disease
- The employee has developed/disclosed a disability; advice is required about the effects of the disability and potential adjustments in relation to the condition
- Following an accident at work that has caused, or is likely to cause a significant absence
- Other – please describe below and provide additional information
Previous Absence (include last 24 months, indicating dates, reasons, self-certified/fit note etc.)
Current Absence Details
Is the employee currently absent?*
- Yes
- No
Fit Note / Medical Certificate?*
- Yes
- No
Reason for current absence:
Any other useful information (including Bradford score, patterns, notes on Fit Note for return to work etc.)
Please indicate the advice being requested by Referring Manager
- Is there an underlying health problem causing the pattern/level of absence?
- If a health problem exists, could it be a disability in terms of the Equality Act 2010?
- Is there any additional help/treatment that might be recommended?
- Where the employee is off work, please indicate timescales of when the employee is likely to return to work.
- Whether at work or not, what is the employee’s current state of fitness for work?
- Are there any reasonable adjustments that are likely to alleviate the health condition and/or facilitate workplace rehabilitation?
- Is there a need to seek a significant alteration or alternative to the current post? If yes, please offer specific recommendations regarding this
- Is there any likelihood that the work environment may be contributing to reduced performance or sickness absence?
- Will this person be able to contribute fully within their post either; when at work, upon and following return to work or at any point in the future?
- The employee is part of a pension scheme and has enquired about retirement on health grounds. Please give relevant advice to them and management in this respect.
Additional Information or Questions
Referral Purpose/Process – Confirmation
Please note: if the employee has not been informed of the referral purpose, the OHA will not be able to proceed with the assessment. This document forms part of the clinical notes and is treated as medical in confidence. The content of this document will be discussed with the employee to enable the consultation process to proceed. The employee’s consent is required for the assessment to take place. With the employee’s consent and following the appointment, Gipping Occupational Health will send a report to the referring manager and to HR. A copy will also be sent to the employee. Due to the legislative and professional requirements of medical confidentiality, the OHA may be restricted in the information he/she is able to provide; where this significantly restricts feedback it will be indicated in the report. I have read the statement above and confirm I have obtained consent from the employee to share the personal data relevant to this referral with Gipping OH, I have discussed the content of the referral form with the employee and confirm that they understand the reason for this referral.
Name of referring Manager*
First Last
Date*
DD slash MM slash YYYY
Referral Checklist - Only select if items are included
- The employee’s job description. If none available please attach a summary of duties & responsibilities
- Accident report (if relevant)
- Other documents (please give details)
Referral (other)
Referral initiated by:*
- Line Manager
- HR Advisor
- Other (please specify)
Referral initiated by (other)
A copy of this referral has been sent to HR*
- Yes
- No

Company Details

Employee Details

Reason for Referral

Current Absence Details

Referral Purpose/Process – Confirmation

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