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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

 

Department

 

 

 

 

 

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

 

Lasers

 

Animals at work

 

Pesticides

 

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

 

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

 

Lone working

 

Genetically manipulated organisms

 

Lead

 

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)

q

Frequent or Recurring Shorter Episodes of Sickness-Absence

q

Health-Related Performance Issue

q

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

q

Rehabilitation

q

Other (eg. ill-health retirement)

q

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

q

 

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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