Proteus Occupational Services

Independent Occupational Medical Services
across the South West

book an appointment

Home
Occupational Health
HSE Medicals
Consultancy
About
- About Us
- Fees
Contact

Occupational Health Referral Form

This form should be used to refer an employee to Occupational Health. Referring Managers must fully complete this form with all relevant information. Incomplete forms cannot be processed and will be returned to the Referring Manager.

Please note that if you do not fill in all the required fields, denoted by “(required),” your form will not be submitted.

Facebook

This field is for validation purposes and should be left unchanged.

SECTION 1 – EMPLOYEE DETAILS

Surname:(Required)

Title:(Required)

Forename(s):(Required)

Job Title:(Required)

Date of birth:(Required)

Day

Month

Year

Unit/Dept:(Required)

Address

Street Address Address Line 2 City County / State / Region Postcode

Employee Number:

Contact Number:

SECTION 2 – REASON(S) FOR REFERRAL

This referral has been submitted for the following reason(s):(Required)

Employee has been absent from work on a number of occasions in recent weeks/months

Employee is absent on a long-term basis (over 4 weeks)

I have identified particular trends with the employee’s absences (as detailed in Section 4)

I have identified that there may be a potential health condition (as detailed in Section 4) which is causing concern over the employee’s ability to perform their duties

Prior to the employee's return to work, I require an opinion on their fitness/ability to return in full/or part to their job.

Other: (Please enter the reason below)

Other Reasons(Required)

SECTION 3 – SICKNESS ABSENCE DETAILS (Up to 24 months)

Please attach an absence printout noting dates, absence reasons and numbers of days lost, or note absence details below. Please add extra rows if needed.

From Date

Day

Month

Year

To Date

Day

Month

Year

Days lost

Absence Reason

From Date

Day

Month

Year

To Date

Day

Month

Year

Days lost

Absence Reason

To Date

Day

Month

Year

From Date

Day

Month

Year

Days lost

Absence Reason

To Date

Day

Month

Year

From Date

Day

Month

Year

Days lost

Absence Reason

To Date

Day

Month

Year

From Date

Day

Month

Year

Days lost

Absence Reason

Is the employee currently absent from work?(Required)

Yes

No

Absence Start Date:(Required)

Day

Month

Year

Medical certificate expires:(Required)

Day

Month

Year

Reason noted on medical certificate:(Required)

SECTION 4 – REFERRAL INFORMATION

Please provide as much relevant detail as possible on the employee’s situation.

Specific questions for Occupational Health

Please read the following questions carefully and select, yes or no against relevant questions you wish to ask from the list below, or type your own in the space provided.

1. When is the employee likely to be fit enough to return to work?

Yes, I wish to ask this question

No, I don't need this answered

2. Are there any restrictions/reasonable adjustments that are recommended for consideration, and for how long might they be required?

Yes, I wish to ask this question

No, I don't need this answered

3. Are there and underlying conditions causing or contributing to the employee’s absence?(Required)

Yes, I wish to ask this question

No, I don't need this answered

4. Is there likely to be a need to seek alternative duties?(Required)

Yes, I wish to ask this question

No, I don't need this answered

5. Eligibility for termination of employment on grounds of ill health within the terms of the company’s pension schemes?(Required)

Yes, I wish to ask this question

No, I don't need this answered

6. Is it likely that the employee’s condition and/or its effects may be considered within the scope of the Equality Act (2010)(Required)

Yes, I wish to ask this question

No, I don't need this answered

7. Are there any implications for the employee’s future work performance, attendance and/or safety?(Required)

Yes, I wish to ask this question

No, I don't need this answered

8. Is there any additional support that the employer could consider that would assist the employee?(Required)

Yes, I wish to ask this question

No, I don't need this answered

9. Other specific advice?(Required)

Yes, I wish to ask this question

No, I don't need this answered

Other specific advice? Please specify.(Required)

SECTION 5 – SUMMARY OF KEY DUTIES/ENVIRONMENT

Please provide a summary of the employee’s role/working environment

SECTION 6 – REFERRING MANAGER DETAILS

This section must be completed in full before the referral is sent to Occupational Health

Manager’s Name:(Required)

Job Title:(Required)

Unit/Dept:(Required)

Tel No:(Required)

Managers' Email:(Required)

HR Contact: (If applicable)

Date:(Required)

Day

Month

Year

Referring Manager’s Declaration

I have discussed this referral and the reasons for it in full with the named employee and issued them with a copy of the referral. I confirm that I understand that the full content of this referral will be shared with the named employee when they attend for an appointment.(Required)

Yes

No

I have obtained the employee’s consent to refer them to occupational health, in accordance with the Proteus Occupational Medicine Services policy on management referral and data protection, as detailed below.(Required)

Yes

No

If ‘no’ above – please document any efforts made to contact the employee being referred(Required)

ATTACHMENTS – Tick as appropriate to the circumstances of the referral (not all required)

Job Description

Sickness Absence Printout *Not required if Section 3 completed

Relevant Correspondence

Notification of Work Related Stress

Relevant Risk Assessment(s)

Additional sheets (e.g. for Section 2 or 5)

File upload

Drop files here or

Accepted file types: pdf, jpg, , Max. file size: 5 MB.

What happens next?

Completed referral forms should be emailed to your local HR Team. The referral form will then be reviewed and passed to Occupational Health. HR advice may be provided at this time if appropriate.

The Occupational Health Appointment

Once a referral has been sent to the Occupational Health, they will endeavour to see referred employees within 1 week.

The Occupational Health Report

Following the appointment, an Occupational Health report will be typed up and returned to the Referring Manager within 7 working days. On receipt of the Occupational Health report, it will normally be appropriate (but not necessarily in all cases) for the Referring Manager to arrange a follow up meeting with the employee to discuss the report and any recommendations made within it.

SECTION 7 – MANAGEMENT REFERRAL DATA & CONSENT

As your employer’s OH service provider we need to process your personal identifiable information e.g. name, date of birth, national insurance number, personal medical information (data). This covers virtually everything that can be done with data, including collection, recording, storage, disclosure by transmission, erasure, and destruction. Your data will be processed in accordance with the Data Protection Act 2018 (UK). Proteus Occupational Medicine Services (POMS) provides a confidential occupational health service. Your POMS records are “medical records” and we have a duty to not share your private medical information with anyone else without your informed consent, unless the safety of individuals or others could be at risk of serious harm, which overrides duty to confidentiality, or a court order is issued.

Who will have access?

Our clinical staff – to perform assessments and provide advice.
Admin staff on a “need to know basis” e.g. to book appointments, process reports etc. All staff understand the need for confidentiality and their contractual obligation to protect it.
3rd party services e.g. laboratories. We disclose only the personal information that is necessary to deliver the service.
Your employer will receive a report on the outcome of your assessment.

We may at times provide statistics to your employer e.g collective results of a referral period. This data will be anonymised so that specific individuals cannot be identified. We may also use your data for internal analysis e.g internal clinical or process audit. If external auditors are used, they would only have access to anonymised data.

How will it be stored?

All data is stored using appropriate secure control measures e.g. encrypted computers, restricted access servers, locked cabinets etc. Most referral related POMS records, unless required for potential/ongoing legal issues, will only be held for six years after your departure from the Employer. NB: We depend on your employer to inform us of your employment status.

Why is it being collected?

Legal obligation: relevant health and safety legalisation and employment legalisation.
Vital Interests: protecting your health from harm.
Legitimate interests: we are acting on behalf of your employer.
For the purposes of preventative or occupational medicine i.e assessment of your fitness for work.
Legal claims relating to any of the above.

What if I have a question or concern?

You can contact us at: contact@proteusoccmedservices.co.uk Please also refer to our Privacy Policy If you are not satisfied with our response or believe we are processing your personal data in accordance with the law, you can contact the Information Commissioner’s Office (ICO)

Employee Personal Details and Consent to Understanding of Declaration

Name:

Date of birth:

Day

Month

Year

Employer

Email

Address:

Telephone No:

I understand how my data will be processed. I consent to assessment and understand that this may involve some physical examinations, the nature of which will be explained to me during the assessment.

Yes

No

I understand that assessment will result in a report being provided to my Employer so that they can consider any workplace adjustments that may help me work.

Yes

No

I declare that any information that I provide as part of this assessment will be true, to the best of my knowledge, and I will not leave out any details which could have a bearing on my state of health.

Yes

No

Signature

If you do not have a touchscreen enabled device, enter your name in the box below, in lieu of a signature.

Name:

Signature

CAPTCHA

Please note that if you do not fill in all the required fields, denoted by “(required),” your form will not be submitted.

It also won’t send if you have rejected all cookies as it requires the Google reCAPTCHA cookie to be enabled to work. Select the circular Cookie icon (bottom left), and click accept all – now try the send button again.

Proteus Occupational Services

HSE Medicals

Fitness to Dive
Asbestos Medical
Ionising Radiation Medicals
Hand-Arm Vibration Syndrome (HAVS) Assessments

About

About us
Fees
Contact us

Occupational Health

Consultancy Services

Policies

Privacy Policy
Cookie Policy
Website Terms and Conditions

Proteus Occupational Medicine Services

Registered office: 24 Cornwall Road, Dorchester, Dorset, DT1 1RX
Company Registration Number 11427664

Website designed and maintained by www.whataboutawebsite.co.uk