BHSFOH Form 14/1
Referral to Occupational Health Form
Section A - Employee Details
Mr/Mrs/Miss/Ms/Dr
Name
Date of Birth
Address
Telephone no. (landline and mobile):
GP Name
Company
Telephone no.
Date of Referral
Line Manager (if different from referring
manager)
Date of appointment (if booked)
Section B
Details of the reasons for referral and any action already taken, including dates of any sickness absence.
Section C
Nature of employee’s job (include level of managerial responsibility, physical effort required to do job, shift
patterns, high risk exposures, amount of driving involved etc. Include a job description if relevant)
Section D
Please detail the information you require from Occupational Health. Please tick the relevant boxes of the
questions you would like answered below. You may add further questions or a more detailed statement
of your own. (This form will expand to include your additions).
 1) Is there a single underlying reason to account for numerous short term absences?
 2) Does the condition have any implications for work performance/attendance/ job content?
 3) Is there anything that will assist the employee to return to work?
 4) What are the likely timescales involved for a return to work?
 5) Will a period of rehabilitation be required and if so, in what form i.e. reduced hours or modified duties?
 6) On return to work, is there likely to be any residual disability which will prevent them from being able
to carry out normal duties and, if so, for how long is this likely to last?
 7) Will the employee ever be able to return to full duties or is redeployment necessary?
 8) Is the condition likely to cause frequent periods of absence?
 9) Is the individual likely to be regarded as having a disability for the purposes of equality legislation?
BHSFOH Form 14/1 Referral to Occupational Health Form
Version 4
Page 1 of 2
Section E – Authorisation
I confirm that I have discussed the reasons for referral to the Occupational Health Service with the
employee, that attendance at Occupational Health is in line with company policy and that information
disclosed to Occupational Health by me maybe disclosed to management where such information will assist
in determining fitness for employment.
Manager: (Signed)
Email address:
(printed)
Date:
Date employee informed of reason for
referral:
Company address:
Contact telephone no:
Invoice address (if different from above)
TO BE COMPLETED BY EMPLOYEE
I confirm that I have read this referral form and the reason for which I have been referred to Occupational
Health has been explained to me. I understand that I am entitled to a chaperone and that I may request
one for this or any subsequent face to face consultation.
Signed: ………………………………………………………………………………….
Print: ……………………………………………………………………………………..
Date: ……………………………………………………………………………………..
On receipt of this form, BHSF OH will contact you to arrange an appointment for your employee with either
an Occupational Health Advisor or Occupational Physician, as appropriate. Unless otherwise agreed, it is
your responsibility to inform the employee of these arrangements. Following the appointment, you will
receive written confirmation of the outcome, including recommendations for any further appointments that
may be necessary.
BHSFOH Form 14/1 Referral to Occupational Health Form
Version 4
Page 2 of 2