Health Education East of England

GP Trainees

OCCUPATIONAL HEALTH SERVICE

MANAGEMENT REFERRAL PROFORMA

Please Print Failure to fully complete this form may delay the appointment

Name of Employee:
Address: / * DOB:
Tel No Work
Tel No Home
* Mobile No:
E-Mail:
Training Unit:
Hospital Ward/Department/Training Practice:
Position:
General Practitioner(of Trainee):
Referring Manager:
Job Title: Training Programme Director
Work Address:
Tel No Work:
E-mail:

*  Required

The Manager seeks clarification on the following. Tick boxes as appropriate

The employee’s sickness absence is above the accepted level, therefore I seek clarification whether there is an underlying significant medical factor. (Agree access to ESR Sickness Absence Data)
Does the employee’s health status currently, or is it likely in the future, to fall under the Equality Act 2010 if so, please indicate if reasonable workplace adjustment is, or will be required
Does the employee require modification to his/her work if so, please specify (to include time-scale)
Will a graded return to work be necessary for this employee, if yes, please indicate time scales
Will further medical information be required prior to the outcome of the assessment and availability of recommendations
Will the employee’s current problem merit application for Ill Health Retirement.
Please indicate if known, when the employee is expected to return to work.
Will a review appointment in the Occupational Health Service be required, if so please indicate an expected period for follow up.
Please give an overview with respect to the reason for referral, which should include any physical, mental, behavioural or dependency problems. If it is necessary for you to give further specific information, please attach a letter with further details.

TRAINING AGREEMENT TO BE ASSESSED BY THE OCCUPATIONAL HEALTH SERVICE

AND CONSENT TO DISCLOSE INFORMATION

I confirm that I understand the reason why I have been referred by my Training Programme Director to be assessed in the Occupational Health Service and agree to be assessed by the Occupational Health Nurse Adviser or Occupational Health Physician.
I confirm that I have received and read a copy of the Management Referral Form.
I understand that at the end of the assessment, a report will be sent to my Training Programme Director and copies sent to myself, my General Practitioner, Southend Human Resources and Southend Occupational Health Service (for Central Occupational Health Records).
I understand that implementation of any Occupational Health recommendations will be made at the discretion of the Training Programme Director as to whether such recommendations can be accommodated.

Signed ______

Trainee

Date ______

All referrals by Management must include the following

  1. Completion of this form
  1. Employee’s written consent
  1. Current placement role and tasks
  1. Sickness Absence record for the previous two years.
  1. Please advise the employee to bring a list of any medication

taken and the dosage, when they attend the Occupational Health Service

Training Programme Director’s Signature______

Date ______

My Preferred location to be assessed is (please tick appropriate location from the list):

Southend Occupational Health Service

Cambridge Centre for Occupational Health

Hinchingbrooke Occupational Health Service

Lister Hospital

Suffolk Occupational Health

Please return the completed form to:

Occupational Health Service

Thamesgate House

33 Victoria Avenue

Southend on Sea

Essex SS2 6BU

©\Occupational Health Service\manref1a\OCTOBER2001 Amended March 2002/June 2002/Aug 2002/Jan 2003/Jan 2004/Jan 2005/ June 2005/March 2009/July 2009/September 2009/June 2010/October 2010/March 2011

East of England GP List of Occupational Health Hospitals

Contact Name and Number / Address
Dr Stuart Miller
Consultant Occupational Health Physician
Tel No. 01438 286514
Fax No. 01438 286721 / Lister Hospital
Coreys Mill Lane
Stevenage
Herts SG1 4AB
Dr Anne Price MB.ChB (Honours), MFOM
Consultant Occupational Health Physician
Tel No. 01480 84 7405
Email: / Hinchingbrooke Health Care NHS Trust
The Occupational Health Service
Hinchingbrooke Park
Huntingdon
Cambridgeshire PE29 6NT
Dr Jose Sanchez
Occupational Health Physician
Tel No. 01473 704011 / Suffolk Occupational Health
Ipswich Hospital NHS Trust
Health Road
Ipswich
Suffolk IP4 5PD
Dr Geraldine Martell
Consultant, Occupational Health
Tel No. 01223 216827
Email: / Cambridge Centre for Occupational Health
Cambridge University Hospitals NHS Trust
Addenbrooke’s Hospital
Cambridge CB2 0QQ
Dr Grahame Sofoluwe
MB BS MRCS LRCP DCH DRCOG MRCGP AFOM Msc CUEW
Occupational Health Physician
Tel No. 01702 385544
Email: / Occupational Health Service
The Deirdre Gray Centre
Suite 40 Thamesgate House
33 Victoria Avenue
Southend on Sea
Essex SS2 6BU

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