NOTES ON HOW TO APPLY FOR A PARKING PERMIT
ON THE BASIS OF A MEDICAL CONDITION

Please complete Section 1 on both Form A and Form B.

Form A should then be forwarded to:
OUH Car Parking Team
Operational Estates Office
Industrial Block
JOHN RADCLIFFE HOSPITAL

Form B should then be taken to your GP for completion.

Section 2 of Form A will be completed by the OUH Car Parking Team and
forwarded to Occupational Health (OH).

Section 2 of Form B should be completed by your GP and sent directly to the OH
Department.

Following receipt of both forms, OH will contact you to discuss your application for
a parking permit.

The medical information included in Form B is confidential and will help OH to
assess your eligibility for a permit on the basis of a medical condition.

Following your assessment, OH will complete Section 3 of Form A and return the
form to the OUH Car Parking Team.

No medical information will be passed on without your consent.

Form B will remain in your OH records.
If you have any further queries on this process, please e-mail the
OUH Car Parking Team: [email protected]
Car Parking/OH Information Exchange Form
Version 5, February 2012
FORM A
APPLICATION FOR CAR PARKING PERMIT ON MEDICAL GROUNDS:
INFORMATION EXCHANGE
SECTION 1: (To be completed by applicant)
NAME OF APPLICANT:
I.D. BADGE NO:
JOB TITLE:
DEPARTMENT:
HOSPITAL SITE:
WORK TELEPHONE:
HOME ADDRESS,
INCLUDING POSTCODE:
HOME TELEPHONE:
MOBILE TELEPHONE:
E-MAIL ADDRESS:
MEDICAL REASON FOR
APPLICATION FOR PERMIT:
(if you wish to disclose)
IMPACT STATEMENT: Please describe how your medical condition impacts on your ability to
use other modes of transport (e.g. public transport, bicycle, walking, etc) for your journeys to
and from your place of work.
SIGNATURE:
DATE:
Car Parking/OH Information Exchange Form
Version 5, February 2012
SECTION 2: (To be completed by the OUH Car Parking Team)
APPLICATION HISTORY / TRAVEL INFORMATION:
include walk/bus/cycle times and routes)
(including details of journey to
SECTION 3: (To be completed by OH)
OUTCOME OF OH ASSESSMENT:
APPLICATION SUPPORTED BY OH:
OH REVIEW REQUIRED IN:
ADDITIONAL INFORMATION:
SIGNATURE:
NAME (BLOCK CAPITALS):
DATE:
Car Parking/OH Information Exchange Form
Version 5, February 2012
YES
1 YEAR
□
□
□
3 YEARS □
NO
FORM B
INFORMATION FOR CAR PARKING PERMIT ON MEDICAL GROUNDS:
INFORMATION FROM GENERAL PRACTITIONER
PLEASE COMPLETE SECTION 1, THEN FORWARD THE FORM TO YOUR GP FOR
COMPLETION OF SECTION 2.
PLEASE NOTE: ANY FEE PAYABLE FOR THE COMPLETION OF THIS FORM BY A GP WILL
BE PAYABLE BY THE APPLICANT AND NOT THE
OXFORD UNIVERSITY HOSPITALS NHS TRUST.
SECTION 1: (To be completed by applicant)
NAME OF APPLICANT:
DATE OF BIRTH:
HOME ADDRESS:
PLACE OF WORK:
IMPACT STATEMENT: Please describe how your medical condition impacts on your ability to
use other modes of transport (e.g. public transport, bicycle, walking, etc) for your journeys to
and from your place of work.
SIGNATURE:
Car Parking/OH Information Exchange Form
Version 5, February 2012
DATE:
SECTION 2: (To be completed by GP)
IMPACT STATEMENT: Please describe how your patient’s medical condition outlined above
impacts on their ability to use other modes of transport (e.g. public transport, bicycle, walking,
etc) for their journeys to and from their place of work. Please give factual medical information
only. This form is not seeking an opinion on whether you do or do not support your patient’s
application. Please note this medical information will not be passed on to the employer but will
be used by the Occupational Health Department to assess eligibility for a parking permit on
medical grounds.
Has your patient sought/complied with treatment for this medical condition?
Yes
/
No
( Please circle as appropriate)
NAME:
DATE:
SIGNATURE:
PRACTICE STAMP:
PLEASE RETURN THIS FORM TO:
OCCUPATIONAL HEALTH DEPARTMENT,
OXFORD UNIVERSITY HOSPITALS NHS TRUST, JOHN RADCLIFFE HOSPITAL,
HEADLEY WAY, HEADINGTON, OXFORD, OX3 9DU.
Car Parking/OH Information Exchange Form
Version 5, February 2012