Employee Payroll Number:
Department Cost Code:
HR Officer email (required):
Home Address & Postcode:
Home Tel No:
Word Tel No:
Mobile Tel No:
Absence Record (Details of any Sickness in the Last 2 Years) or attach Sickness Record:
Please state all absences including reasons on medical certificate. Including start and end dates:
Please select the appropriate reason/s:
Health Related Performance IssueRehabilitationPossible Work Related Health ProblemLong Term Sickness AbsenceShort Term Sickness AbsenceIll Health Retirement
Please select the appropriate option/s:
Lifting/Carrying LoadsVibrating ToolsWelding/CuttingWork at Height (ladders/roof)Oils/Paints/DieselRadiation – Ionising/Non IonisingUse of Latex GlovesHazardous Micro-OrganismsClinical WasteDusts and ParticlesVulnerable GroupsChemicalsAnimalsPesticidesAsbestosFood HandlingLone or Night WorkingNoiseLeadExtreme TemperaturesDriving (car/van/PCV/LGV)
Other, please specify:
Office HoursEarly ShiftsLate ShiftsNight Shifts2 Shifts3 Shifts
Please outline the main issues initiating this request including the affects of the health problem on work performance and attendance:
Please specify the advice requested. (Examples of the questions Managers may wish to ask are below)
Please select the questions that you would like answered in the report:
Is there an underlying medical condition affecting this individual’s performance or attendance at work?Is the employee currently fit to carry out the duties outlined in the job description?Are there any short term adjustments to the work tasks or environment that would help facilitate rehabilitation or an early return to work?Please specify what adjustments should be made and how long should these adjustments continue?Are there any permanent adjustments to the work tasks or environment recommended?What is the likely timescale for recovery and/or when do you anticipate a return to work?Is there further requirement for medical support or intervention?Is the health problem likely to recur of affect future attendance?In your opinion, does the health problem meet the criteria of disability as defined by the Equality Act 2010?Fitness to attend a disciplinary hearing
(Regarding disciplinary hearing:)
1. Does the employee have the ability to understand the allegation made against them?
2. Does the employee have the ability to distinguish right from wrong?
3. Is the employee able to instruct another person to represent their interests?
4. Does the employee have the ability to understand the proceedings, if necessary with extra time and written explanations provided?
Other information (e.g. opportunities for job adjustment or redeployment/any outstanding disciplinary procedures)
I confirm that I have discussed the reasons for this referral with the employee:
Please indicate by ticking or highlighting the appropriate boxes what supporting documentation is being included with this completed referral request:
Job DescriptionSickness RecordMaterial Data Sheets
Other documentation relevant to this case e.g. GP/Specialist report. Please specify:
You can upload up to 5 separate files. You may not upload .zip or .rar.