Human Resources – Advisory Team
OCCUPATIONAL HEALTH ADVICE REFERRAL
EMPLOYEE DETAILS – PERSONAL
Surname (please print) ............................................................………...… Mr/Mrs/Miss/Ms…………….....
Forenames (please print) .......................................…..………………….... Date of Birth ………….……….
Current Address .......…......................…...……………………………………................................................
...........................................................................................................…….. Post Code ……….....……......
Tel. No (Daytime where Contactable) Home tel. Number …………………………………......………………
Work tel. number........................................................................ Mobile ....................................................
Email where contactable: ........................…….............................................................................................
Division/Location/Department ……………………………………………………………………………………..
REFERRING MANAGER’S DETAILS
Name ...................................................................... Job Title .....................................................................
Location Address ......…......................…...……………………………………................................................
...........................................................................................................……... Post Code ……….....……......
Tel number .......................................…..…………… Email ……….…..............……....................................
For Office Use Only (This section must be filled in by HR Dept or Line Manager)
All correspondence regarding this questionnaire should be returned to:Name: ................................................................................... Telephone: ...................................................
Address: …..……..……………..……..……………..……..…….........................…..……..……………….……
…..……..……………..……..……………..……..………..……... Post code: ...................…………….….……
Email: .…..……..………………….…..……..…………..………. Purchase Order No ….....................……….
Copy Report by Email to: ………………………………………………….…………..…....…………………….
HISTORY OF ABSENCE AND PRESENT REASON FOR ABSENCE
Reason for referral / absence:
Date absence commenced:
[if applicable]
Total Number of days absent to date:
No of Days absent in last 12 months including
reasons for absence (Please attach printout if
available) (Continue on a separate sheet if
necessary):
Has the individual been referred to
Occupational Health before?
If so, when?
Medigold Health Consultancy Ltd 2009 Quest NOHP 203
EMPLOYEE DETAILS – JOB DESCRIPTION
What is the employee’s job title?
JOB DESCRIPTION ATTACHED
Please describe the main aspects of the
employee’s job.
Is the employee employed in a management or a
supervisory capacity?
Yes
No
If so, how many staff does the employee directly
control?
What hours does the employee work?
Are there any unusual aspects of the employee’s
hours of work?
Shift work
Yes
Weekend Work
Yes
Being on Call
Yes
Other – please detail below:
No
No
No
Does the employee deal with the public, either
face to face or via the telephone?
WORK ENVIRONMENT
In what area does the employee work (e.g. office,
outdoors, factory, etc)? If more than one, please
indicate percentage of time.
What machines or equipment does the employee
use (i.e. VDU)?
Are there any environmental conditions that
aggravate the claimant’s disability (e.g. dust,
fumes, heat or cold, noise, etc)
PHYSICAL REQUIREMENTS OF JOB
Are the physical demands of the job:





Sedentary?
Manual?
Involving lifting weights over 10kilos
Require the use of power or vibrating tools?
Prolonged outdoor exposure?
What percentage of the day is spent driving?
Medigold Health Consultancy Ltd 2009 Quest NOHP 203
JOB SKILLS
What formal qualification, if any does the claimant
need to do his/her present job?
What special skills are required?
What level of experience is required?
Specify any special intellectual demands (e.g.
communication, calculation, problem solving, etc)
PERFORMANCE
Has there been a change in attitude towards the
standards of the job required?
Has there been a change in timekeeping (i.e.
lateness, short term absences)?
Has there been a change of attitude towards
colleagues?
Please detail any changes of behaviour or
attitude that have occurred.
Have any disciplinary or grievance procedures
taken place within the last six months?
ADJUSTMENTS
Please indicate whether there has been:
A change of duties/tasks
A change of hours
A change of location or working are
A change of working procedures
Additional training (i.e. lifting)
Additional equipment
Any other changes or adjustments made
Medigold Health Consultancy Ltd 2009 Quest NOHP 203
Are there any other positions/jobs/tasks available
either short term or long term? If so please
describe them.
Have you interviewed the employee since their
absence? If so what was the outcome?
Please give any other information you may feel is
helpful. (please use additional sheets if needed)
CHECKLIST OF DOCUMENTS (please tick if included)
Access to Medical Reports Act 1988 Consent form – COMPLETED AND SIGNED
Referral Letter or Form
History of Absences – e.g. absence record chart, meeting notes, return to work
interview notes, etc.
Copies of Self Certifications
Copies of GP Certificates
Job Description and Person Specification
Any other relevant information:
 Executive summary relating to, for example:
o disciplinary/grievance meetings (within 6 months)
o performance review
o other background information
 Risk Assessment
 Other
Invoice Information, including Purchase Order Number if necessary
Medigold Health Consultancy Ltd 2009 Quest NOHP 203
QUESTIONS TO BE ANSWERED BY OCCUPATIONAL HEALTH PHYSICIAN
Is this a temporary condition or problem or is it likely to be long-term or permanent?
How does the condition affect normal day-to-day activities?
Would you consider the condition to form a long-term disability?
Is the employee fit for their post/position/grade at present?
Is there evidence of any work related element to the health problem? If so, in what way.
Does the condition impose risks to the safety of other employees? If so, in what way
What is the likely outcome of this ill health period?
Is there likely to be a residual impairment or re-occurrence of this condition?
Are there any duties appropriate for this employee that they would be able to undertake?
Is the employee capable of working their current standard contracted hours?
Is a gradual return to work recommended? If so, on what basis
Are there any other actions/adjustments that the company could make to facilitate a return
to work?
When is a return to work likely? Please outline anticipated timescales.
Are there any further opinions that the company should obtain to manage a return to work?
Is this condition covered by the Disability Discrimination Act?
Please Consider this person for Early Ill Health Retirement. Would Early Ill Health
Retirement be supported?
OTHER QUESTIONS YOU WOULD LIKE ANSWERED (please list)
Referring Manager’s Signature ................................................................. Date ....................................
Medigold Health Consultancy Ltd 2009 Quest NOHP 203