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:

Travel and Transport Co-ordinator

Operational Estates Office

Industrial Block

JOHNRADCLIFFEHOSPITAL

  • Form B should then be taken to your GP for completion.
  • Section 2 of Form A will be completed by the Travel and Transport Co-ordinator 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 Travel and Transport Co-ordinator.
  • 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

Travel & Transport Co-ordinator:

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 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:
SECTION 2: (To be completed by Travel & Transport Co-ordinator)
APPLICATION HISTORY / TRAVEL INFORMATION: (including details of journey to include walk/bus/cycle times and routes)
SECTION 3: (To be completed by OH)
OUTCOME OF OH ASSESSMENT:
APPLICATION SUPPORTED BY OH: / YES □ NO □
OH REVIEW REQUIRED IN: / 1 YEAR □ 3 YEARS □
ADDITIONAL INFORMATION:
SIGNATURE:
NAME (BLOCK CAPITALS):
DATE:

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: / 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, JOHNRADCLIFFEHOSPITAL, HEADLEY WAY, HEADINGTON, OXFORD, OX3 9DU.

Car Parking/OH Information Exchange Form

Version 4, November 2011