Occupational Health Assessment Referral Request

Email

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Consent(Required)

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I agree

Referrer Details

Company Name(Required)

Company Address(Required)

Street Address Address Line 2 Town / City County Postcode Country

Referrer First Name(Required)

Referrer Last Name(Required)

Referrer Job Title(Required)

Referrer Telephone #(Required)

Referrer Email(Required)

Employee Consent

Has referral been explained to employee?(Required)

Do you confirm that the reason for this referral has been fully explained to the employee and that the employee agrees with the referral to UKIM Occupational Health & Wellbeing and understands that an occupational health advice will be available to you, the employer, with their consent advising you about how you might be able to help him/her from a work perspective taking into account the employee’s current health problems/symptoms/underlying condition(s)

Yes

No

Has employee consented to consultation?(Required)

Do you confirm that the Employee consents to the consultation taking place and that the content of the Occupational Health Advice will be discussed and agreed with him/her during the consultation with the UKIM Occupational Health professional

Yes

No

Has employee consented to information retention?(Required)

Do you confirm that the Employee consents to UKIM Occupational Health & Wellbeing retaining relevant personal and health information as required in order to process this referral and that they understand their rights under the Data Protection Act (further information can be found at WWW.ico.org.uk)

Yes

No

All consents must be confirmed before proceeding.

Employee Details

Employee first name(Required)

Employee last name(Required)

Employee Date of Birth(Required)

Employee Telephone #(Required)

Employee email address(Required)

Employee job title(Required)

Referral Details

Reason for referral(Required)

Please provide full details of the specific reason for this referral (Required)

What action has management taken in dealing with this case to date?(Required)

What is the expected outcome of the referral to occupational health?(Required)

Give details of their normal duties, any physical demands within their job and working environment?(Required)

Normal weekly working hours(Required)

Is the employee currently absent from work?(Required)

Yes

No

Start date of absence(Required)

Reason for absence(Required)

Is the absence a result of an accident at work or work related ill health? If so, please provide details

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UKIM Occupational Health & Wellbeing On-Demand

Occupational Health Assessment Request