ࡱ> W cbjbj\\ >i>i   lllll8tf:&0t[ T , y9{9{9{9{9{9{9$<B?9l 9 "[ 9ll :a#a#a# :ll8a# y9a#a#3|4me-!@7486:0f:I4 @m! @$44f @lQ5X a# 99"B f: @ X 2: UCL HUMAN RESOURCES WORKPLACE HEALTH MANAGEMENT REFERRAL FORM STRICTLY CONFIDENTIAL Please consider discussing your referral with your HR Business Partner. Once completed please email to: HYPERLINK "mailto:wh.occupationalhealth@ucl.ac.uk"wh.occupationalhealth@ucl.ac.uk 1. Employee details:Surname:  FORMTEXT       Title:  FORMTEXT       First name:  FORMTEXT      Department:  FORMTEXT      Job title:  FORMTEXT      Date of Birth:  FORMTEXT      Mobile:  FORMTEXT       THIS FIELD IS MANDATORY - Workplace Health team will call to arrange the appointmentUCL email:  FORMTEXT       Personal email:  FORMTEXT      Are there any particular requirements in relation to access, mobility or communication? If yes please give details:  FORMTEXT      If the employee is unable to participate in a consultation, please discuss the case with your HRBP. In some circumstances we can contact the treating clinician directly with the employee s consent. 2. Referring manager / supervisor:Manager: FORMTEXT      Job Title: FORMTEXT       Department:  FORMTEXT       Contact number:  FORMTEXT      Email: FORMTEXT      HRBP / ER Manager name: FORMTEXT      3a. Reason for referral. Please outline the main issue(s) initiating this request, including the effects of the health problem on work performance and attendance:  FORMTEXT       3b. If stress related  has a stress risk assessment been completed? If yes, please share any mitigations you have agreed and the date the assessment was completed.  FORMTEXT       3c. Sickness absence previous 12 months: Days:  FORMTEXT       Occasions:  FORMTEXT       Currently on sick leave:  FORMTEXT      4a. Please provide a brief overview of the employee s duties and potential job hazards, and identify here what, if any, work adjustments have already been considered or implemented.  FORMTEXT       4b. 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FORMCHECKBOX Are there any duties the employee will be unable to carry out when they return to work? FORMCHECKBOX Is the employee fit to undertake their role? FORMCHECKBOX  Is the condition likely to recur and what might be the impact on attendance in the future? FORMCHECKBOX If the employee is unfit, when is the employee likely to be fit to return to work? FORMCHECKBOX Is the employee s health concern related to the work environment? FORMCHECKBOX Are there any adjustments that may support the employee at work / facilitate their return to work?  FORMCHECKBOX In OH s opinion, is it likely or unlikely that the disability provisions of the Equality Act 2010 will apply in this case? FORMCHECKBOX How long will the recommended adjustments be required for? FORMCHECKBOX Does the condition cause any further risk to employees, students or patients in their area of work? If so how can these be minimised? FORMCHECKBOX  Please add any additional queries you have here:  FORMTEXT       5. Referral authorisation (the referring manager named above must sign here). Please complete the following by ticking the boxes below:  FORMCHECKBOX  I confirm that I have discussed the reasons for this referral with the employee and the HR Consultant.  FORMCHECKBOX  I have passed a copy of this referral to the employee.  FORMCHECKBOX  I am aware that the employee will receive a copy of the resulting report. PLEASE NOTE: if the employee is unaware of your reasons for referral we may not be able to complete this assessment.If completing electronically type your name below. This indicates your agreement to the above statements (section 6) and must be emailed from your named UCL email account. Alternatively, print the form, sign and scan as a PDF file. 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