Portsmouth Hospitals NHS Trust
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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.

Managers 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.

Working together to drive excellence in care for our patients and communities


Queen Alexandra Hospital
Cosham, Portsmouth
Tel: 023 9228 6000

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