Centre for Occupational Health & WellbeingCenturion House, Tribune Way

Clifton MoorYORK

YO30 4RYTel: 01904 721658

Email: OH.Businessadmin@york.nhs.uk

Occupational Health & Wellbeing Service Business Team

OHB19 Management Referral Form

Strictly Private and ConfidentialInformation about the employeeName

AddressDate of Birth

Age

Contact Details

HomeMobileEmail

Job Title

Department

Date commenced in post

Work Pattern Yes No Current work status Yes NoDaytime shifts only ? Currently off sick ?Night shifts only ? Date sick leave startedRotating shift pattern ? Planned return date (if known)Office hours only ? Recurrent short term absence ?On-call commitment ? Long term sickness absence ?Attached documents Yes No Pay and pension status Yes NoJob description Currently on full pay ?Risk Assessments Currently on half pay ?Sickness Absence Profile Date sick pay expiresProceeding to Final attendance stage meeting ?

In pension scheme ?

Information about the problemPhysical Problems or Emotional Problems

Action taken so far

/tt/file_convert/5a788d817f8b9a852c8c6915/document.docx Page 1 of 3

Occupational Health & Wellbeing Service Business Team

Advice needed from Occupational Health

In all cases, Occupational Health will offer you the following advice :

Whether there is an underlying medical problem. Whether the employee is fully fit for contracted duties, including hours and current shift pattern. If not, whether the employee could undertake contracted duties with appropriate adjustments. If not (or if adjustments cannot be accommodated) whether the employee could safely undertake

suitable alternative duties. If not, the likely timescale for recovery and return to work. Whether any follow-up arrangements have been made.

If you have any further questions, add them here :

Manager’s InformationI confirm that I have explained to the employee why I am referring him/her to Occupational Health and given him/her a copy of this referral form

Manager’s Name and/or referring person

Job Title

Organisation York St John University

Telephone Number

Email address

Signed Date

Appointment site preferencePlease note your occupational health appointment site preference below. If no preference provided your appointment will be booked at our York Hospital siteYork Hospital siteWigginton Road, York YO31 8HEOccupational Health consulting room opposite the Intensive Care Unit access via the South entranceYork Clifton Moor siteOccupational Health and Wellbeing, Centurion House, Tribune Way, Clifton Moor, York YO30 4RY

Employee’s Consent

I confirm that my manager has fully explained the reasons for referral to Occupational Health and has given me a copy of this referral form. I am / am not (please delete as appropriate) willing to attend for Occupational Health Assessment

Signed Date

Please e-mail the completed form (as a word document) to your Human Resources Advisor or humanresources@yorksj.ac.uk

Guidance for managers on the referral process/tt/file_convert/5a788d817f8b9a852c8c6915/document.docx Page 2 of 3

Occupational Health & Wellbeing Service Business Team

It is appropriate to refer an employee to Occupational Health when information and advice about employee health is necessary for you to make a management decision about that employee. Typical reasons for referral include:

the employee reaching a health indicator point under the sickness absence policy where there may or may not be a significant underlying health problem

the employee has a period of ill health that they do not wish to disclose the employee’s performance or behaviour may be adversely affected by their health where work may be a cause or contributory factor to ill health as an agreed action following a formal or informal review meeting for performance or disciplinary

reasons the employee requests a referral due to concerns about their health and work Mandatory referral to OH Physician prior to final stage attendance meeting

It is essential that the referral is fully completed and the requested information attached. Particular consideration has to be given to the assessment of work demands so that we can relate the employee’s health to their work tasks and environment. Investing time in producing a clear and detailed referral should facilitate an effective assessment and report back to you.

The referral should be discussed between the manager and the employee before it is sent, including possible outcomes following the assessment:Ideal situation – the preferred process in all cases

The manager should meet with the employee and discuss the reasons for the referral. Both parties should agree the detail to be provided to occupational health. Both parties should sign the referral form, which should then be posted by the manager to Occupational Health.

Alternative process, when the employee cannot meet with the manager

If the employee is not available for a face-to-face discussion, this can still be done successfully over the phone. Once the detail has been agreed verbally, the manager should then sign the form and post it to the employee, who should countersign it and take it to the OH appointment.

Last choice – only to be used when telephone contact with the employee has not been possible.

If the employee cannot be contacted by telephone, then a completed and signed referral form should be posted to the employee’s home address with a covering letter explaining why he/she is being referred to OH. The employee should read and sign, then either return it to you or take it to the OH appointment. It is inappropriate for an employee to arrive in OH with no knowledge of the reasons for their attendance.

The employee will be offered an appointment (10 working days for an OH Physician or OH Nurse assessment). We will aim to send you a report within 5 working days of the assessment. You will be informed if the employee fails to attend or attends late. It is unlikely that we will be able to see an employee, who arrives more than 10 minutes late, as this impacts on the next client. Those failing to attend an appointment will be referred back to their referring manager. A further appointment will not usually be sent to the employee until you have discussed the reasons for non-attendance with the employee and obtained his/her agreement that they are still able and willing to attend for OH assessment.

All "personal data" (as defined in the Data Protection Act 1998) supplied in connection with services, including individual case information, shall be processed in accordance with the provisions of the 1998 Act and comply with the NHS Code of Practice on Confidentiality. Further information in relation to confidentiality and disclosing information can be found at www.gmc-uk.org/guidance

Following receipt of the OH report, we want you to feel confident about acting on the information and advice of the assessor. If you have any questions or require clarification, please contact the author of the report directly. You should then discuss the findings and recommendations in the report with the employee before coming to a decision about your management of the employee.Where we suggest a rehabilitation plan or adjustments, including possible temporary or permanent redeployment, it is up to you to decide whether these can be reasonably supported for the period suggested. There may be a cost implication that will have to be borne by your budget.

The decision to implement the recommendations should balance best rehabilitation practice against service constraints. You may wish to contact your HR Manager for further advice. If you do not feel able to implement some or all of our recommendations, you should discuss your reason for this with the employee and record on the "health support plan" which should be retained in the relevant employee file. The law does not require you to invent a post; it asks that you make reasonable adjustments to an existing role where you are able.

/tt/file_convert/5a788d817f8b9a852c8c6915/document.docx Page 3 of 3