PRIVATE & CONFIDENTIAL

Occupational Health Referral Request Form

Please complete fully in BLOCK CAPITALS OR UPPER CASE TYPE and return by

e-mail to occupationalhealth@uhbristol.nhs.uk or Fax on 0117 917 0163.

Incomplete referrals will be returned to sender for completion, delaying the appointment being offered.

Employee Personal Details:
Title:	Surname:	First names:
Previous surnames, including maiden name (if relevant):	Personal Email
Home Address, (including postcode)
Date of Birth:	Gender:
Mobile No:	Home Telephone No:
Job Title:	Full Time / Part Time:
Organisation:	Department:
Work Telephone No:	Date commenced this employment:

Referral made by:
Name:	Position:
Organisation & Department:	Work address:
Contact telephone No. (work):	Email address (work):
Name and contact details of HR representative if they need a copy of the report: Referring Manager – please ensure you inform your HR Manager of this referral - if required by local policy
Signature of Referrer:	Date:

Reason for Referral Request - to be completed by the referring Manager Please tick indicate “X” in the relevant box below, then give as much information as possible on second page attaching additional sheet(s) if necessary
(i)	Long term sickness absence - opinion regarding likelihood of recovery or return, adjustments or recommendations. Please provide date that absence commenced in section on next page.	☐
(ii)	Persistent short term sickness absence - opinion regarding future attendance at work. Please provide details of sickness absence record in section overleaf	☐
(iii)	No sick leave – opinion about a health concern regarding medical fitness to continue at work. Please provide further information in section overleaf	☐
(iv)	Return to work after surgery, illness or accident - opinion regarding fitness for work. Please provide date that absence commenced in section overleaf	☐
(v)	Ill health retirement - opinion as to whether medical criteria met	☐

Cont’d overleaf …

It is essential that the content of this referral is discussed and agreed with the Employee before this form is sent to Occupational Health.

Additional details: (Guidance notes available at www.apohs.nhs.uk) Please provide relevant background to the referral and state what questions you want Occupational Health to answer - for example Sickness Absence Record details over the previous 12 months or longer, if relevant, including reasons given for absence, and the first day of sickness or, attach a copy of the sick absence record, if it contains reasons for the absences. Details of any modifications to the workplace already discussed with the employee – if so, please give details List any workplace adjustments that you have already identified which you could accommodate for this employee Job Specification - give a brief outline of the main activities or requirements of the post, particularly any that you feel are relevant to the referral or attach a copy of the Job Description. Include additional sheets if required.
Click here to enter text.
To be completed by the Manager I confirm that the employee is aware of this referral and has had the opportunity to read this referral form. They understand the reason why they have been referred and they have agreed to attend the Occupational Health Service
Referrer’s Name (CAPITALS):	Date:
Signed:
For further guidance please contact Occupational Health on the telephone number below:
Whitefriars Centre: 0117 342 3400
For OHS use ONLY:
Date referral received:
To be seen by:	Length of appointment:
First Appointment Date Offered:	Actual Appointment Date Booked: