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AseptA Occupational Health Referral
1.
Please provide the following information:
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Which Service is required?
Occupational Health Assessment
OH Physiotherapy Assessment
OH Counselling
OH Gynae/Obstetrician Assessment (Women @ Work)
Early Intervention / Work Design Assessment
Company Details:
Company Name
Address
Telephone
Referrer Details:
Referrer Name
Job Title
Email
Number
Employee Details:
Employee Name
Date of Birth
Address
Email
Contact Number
Job Title
Department
Current work status
Date of first absence day (yyyy-mm-dd)
Main concerns and reason for the referral
Please provide a summary of job role (duties, responsibilities, risks etc)
Please add supporting documentation e.g. job description, risk assessments, reports
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Maximum of 10 files, up to 10 MB each
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Please tick the questions to be answered by occupational health:
1) Is the employee fit for work, please state the reasons why fit/not fit?
2) Is the employee receiving the appropriate care and treatment?
3) Is a return-to-work dependent on any factors?
4) Any actions that the employer can take to facilitate an earlier return to work, and later, to prevent further absence?
5) What is the likely impact on their performance or attendance at work from this condition?
6) Are you able to estimate when a return to work is likely to occur?
7) In your opinion is the employee likely to be covered under the Equality Act 2010. Please give reasons.
8) Is the employee able to attend meetings with management, including disciplinary proceedings?
Consent:
I confirm that the employee has been made aware of the purpose and content of this referral.
Yes
