Occupational Health Services Ltd
Referral for Occupational Health Assessment
This referral is accepted on the understanding that the employee listed below is fully aware of the referral and the questions that are being asked.
1) Employee Details
Title / First Name / SurnameDate of Birth / Job title / Length of service
Address / Contact telephone / Contact email
2) Please provide a full job description/specification detailing tasks, hazards and hours of work
3) Please give all relevant information in the box below to fully explain the reason for this referral, your concerns, and the effects of the health problem on work performance and attendance. Please attach any sickness absence data, date current absence began and relevant GP or specialist reports.
Yes / NoRecurrent short spells of absence causing commercial concern
Yes / NoProlonged sickness and absence
Yes / No Return to work assessment
Yes / No Fitness for Work
Yes / No Before Job Transfer / Modification / Promotion
Yes / No Suspicion that health may be impacting on work performance.
Yes / No Suspected Alcohol or Drug Misuse
Other Please give details below
Are there any disciplinary warnings in force in relation to attendance/performance? If yes, please give details:Has the employee advised you of any concerns they have in the workplace? If yes, please give details:
Have there been any changes to the employee’s performance, timekeeping or motivation at work? If yes, please give details:
Please outline any actions that have been taken to address the problems outlined in the referral:
4) Has the employee been consulted about this referral?Yes/No
5) Referral questions you wish to be addressed by the OH professional.
Yes / No Is there a health condition present and is it likely to be permanent, fluctuating or resolvable?
Yes / No Is there evidence of any work-related element to the health problem, and if so, can you identify the relevant factors?
Yes / No Is the employee fit to undertake normal duties of their current role?
Yes / NoWhen is a return to work likely?
Yes / No If the individual were not fit to fulfil their role, what actions, adjustments / rehabilitation plan is recommended?
Yes / No In your medical opinion, is the employee likely to be classed as disabled under the Equality Act 2010?
Yes / No Is the employee fit to attend a disciplinary meeting or hearing?
Yes / NoIf the individual is not fit to return, is ill health retirement appropriate?
Yes / No Is further OH review recommended?
Yes / No Other – please detail below
I understand that Occupational Health Services Ltd will charge the full fee for cancellations of less than 48 hours notice and that if Occupational Health Services Ltd needs to refer to the employee’s GP or other health professional for further information, this will be discussed with you in advance and any fees incurred will be directly passed on to you.
6) Details of Referring Company / Manager:
Company Name / Company address / Date of requestReferring manager / Telephone / Email
HR Manager / Telephone / Email
Who reports to be sent to / Authorised Name / Authorised Signature
Please email the completed form to
For any questions on completing this form, contact Debbie Holder on 07790807088