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Online Referral

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About

Date Of Referral

Date Of Birth

Post Details

Manager Details

Title

HR Advisor Details (to whom this report should be sent)

Work Place

Reason For Referral

Concerns of impact on other employees/clientsLong term sickness absenceIll health retirement assessmentAlcohol or drugs related problemsInvestigation of workplace illness or injuryOther

Recurrent short term absence - non recurrent causeRecurrent short term absence - single causeConcerns regarding change in behaviourHealth conditions that may be exacerbated by occupational exposureConcerns of impact on other employees/clients

Supplementary job task profile of exposure levels (please check as appropriate)

Q1. Rate of exposure during daily work routine
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q2. Driving - car/van/HGV/PCV/taxi/transporting clients
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q3. Face to face contact with public
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q4. Lone working
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q5. Outside work
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q6. Extremes of temperature
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q7. Psychological stress including violence and trauma
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q8. Supervision of staff
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q9. Vulnerable clients - children/emotionally disturbed/elderly
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%

Q10. Food handling
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q11. Frequent hand washing
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q12. Potential exposure to blood or body fluids
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q13. Use of latex gloves
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%

Q14. Computer/DSE use
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q15. Non DSE desk work
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%

Q16. Noise (greater than 90dba - 8 hrs ta)
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q17. Vibrating tools or work pieces
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%

Q18. Exposure to hazardous substances (eg solvents/liquids)

Q19. Inhalation exposure to hazardous substances (dust/fumes/mist/gas/vapour/chemicals)

Other hazards - eg hazardous or dirty waste

Q20. Ionising radiation

Q21. Pesticides
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%

Manual handling

Q22. Lifting/Carrying up to 10 kgs
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q23. Lifting/carrying up to 25 kgs
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q24. Lifting/carrying over 25 kgs
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q25. Pushing
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q26. Pulling
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q27. Team handling
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q28. Digging/shovelling
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%

Client handling

Q29. Manually assisting clients
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q30. Use of mechanical aids
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q31. Team handlingNever 0%Rarely up to 30%Frequently up to 60%Contanstly >60%

Q32. Crawling
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q33. Crouching/squatting
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q34. Kneeling
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q35. Sitting
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q36. Standing
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q37. Stooping
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q38. Twisting
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q39. Walking
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q40. Reaching at shoulder height
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q41. Reaching above shoulder height
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%

Q42. Climbing heights – step ladders/ladders
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q43. Working at heights – scaffold/roof work
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%
Q44. Confined space work
Never 0%Rarely up to 30%Frequently up to 60%Constantly >60%

Other:

Is the employee fit to work?When will the employee be fit to work?Is the employee likely to have further absences due to his illness?Does this employee meet the ill health retirement criteria?Are the medical problems likely to be made worse or likely to be caused by current work activity?Is the employee likely to be covered under the disability provisions of the Equality Act 2010?Should the person be managed under the Company's medical redeployment scheme or are there any adjustment?What support should be provided, if any, to aid the employee back to work?Is there any underlying medical condition which could account for these absences?Other supplementary questions (Maximum 2):


I have discussed the reason for referral to Occupation Health with the employeeI have provided the employee with a copy of this completed referral documentI have completed of relevant sections within this referral form, specifying the particular questions I require the (need rest of text)I have attached the employees past sickness absence details (where applicable)

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