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Management Referral Form

Personal Details


The questions that I should like answered are, for example:

  • When does Occupational Health anticipate a return to work/full duties?
  • Is there an underlying medical condition affecting the employee's attendance?
  • Is the employee fit to continue in the work place?
  • How does the medical condition affect the employee's ability to carry out normal duties?
  • What is the estimated duration of the employee's absence?
  • What is the employee's predicted date of return to work?
  • Is the employee's medical condition likely to affect future attendance?
  • What are the employee's likely capabilities on return to work?
  • Is the employee fit to perform the duties of the post?
  • Will any adjustments be required to assist the employee's recovery or return to work?
  • Are there any aspects of the role that the employee cannot perform on health grounds?
  • Are the any further supports or interventions to offer the employee in the workplace?
  • Is the employee's problem caused or made worse by work?
  • Does the employee have any additional medical problems we should be aware of?
  • Should re-deployment on health grounds be considered for the employee?
  • If re-deployment is recommended what type of role/duties/hours would be suitable for the employee?
  • Should Ill-health retirement be considered for the employee?

Information about the employee




I confirm that I have discussed with the employee the reason for this referral and he or she fully understands and agrees to attend the Occupational Health Department.*

Manager's Information

To be completed by the Manager/Human Resources Manager (Referrer)

For confidentiality purposes please complete the required information asked in this box:

Incomplete information may cause a delay in receipt of the report. Thank you for your co-operation.