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Management Referral Form to Occup Doc

GENERAL MANAGEMENT REFERRAL to Occ Health Physician for assessment FORM

(Incomplete --We will send you full doc on request)



SECTION 1 – Referring Manager to Complete –and return to NorEast Occupational Doctor Services, 101 Edgehill, Ponteland, Newcastle-Tyne, NE20 9JQ

Manager’s Name


Job Title








SECTION 2 – Employee Details

Employee Name


Description of main duties


Current job description attached

No   q    Yes   q

Are there any particular requirements in relation to access, mobility or communication?

No   q    Yes   q (if yes, please provide details)








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SECTION 3  - Hazards and risks associated with job (please tick appropriate boxes)


Moving and handling


Vibrating tools


Hot temperatures e.g. boiler house


Outside cold work or deep freeze


Frequent hand washing


Psychological stress


Use of latex gloves


Work at height e.g. ladders/roofs


Clinical waste


Radiation: ionising / non-ionising


Vulnerable patients / children / emotionally disturbed clients




Animals at work




Inhalation exposure to dusts, fumes, mists, gases or vapours


Hazardous micro-organisms e.g. lab staff / infectious disease unit


Lone working


Genetically manipulated organisms




Unsociable hours / on call


Food handling


Skin expo

                             SECTION 4 – Reason(s) for Referral (Please þ as appropriate)

Long-Term Sickness-Absence (eg. at 6 weeks)


Frequent or Recurring Shorter Episodes of Sickness-Absence


Health-Related Performance Issue


Possible work-related health problem (eg. skin-rash, sciatica)




Other (eg. ill-health retirement)


Self-referral (where employee has concerns about health and work)



Absence Record (If relevant please give details of any sickness in the last 2 years or attach company’s own separate record for employee )

Reason stated on medical certificates

Valid From

End Date

Number of Days






Please outline the main issues initiating this request, including the effects of the health problem on work performance and attendance.

Please tick any of the following questions relevant to referral

Is there an underlying medical condition affecting this employee’s attendance or performance at work? q


Is the duration and/or pattern of absence reasonable in relation to the condition?  q

Is s/he currently fit to carry out the duties outlined in the job description?  q


Are there any short-term adjustments to the work tasks or environment that would help facilitate rehabilitation or an early return to work?    q


Are any permanent adjustments to the work tasks or environment recommended?   q


What is the likely time-scale for recovery and/or when do you anticipate a return to work?   q


Is there further requirement for medical support or intervention?   q


Is the health problem likely to recur or affect future attendance?   q


Is s/he a suitable candidate for redeployment on medical grounds?   q


In your opinion, does the health problem meet the criteria for disability as defined by the Equality Act 2010?  q



Other information (e.g. opportunities for job adjustment/redeployment, any outstanding disciplinary/grievance procedures)


Please specify any other queries


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