Please Note That No Consultation Will Be Carried out Without a Completed Referral Form

PLEASE NOTE THAT NO CONSULTATION WILL BE CARRIED OUT WITHOUT A COMPLETED REFERRAL FORM

CONFIDENTIAL PAM OH Solutions REFERRAL TO OCCUPATIONAL HEALTH CLINIC AT 126 Bedford Road, Birkenhead, Merseyside, CH42 2AS Tel 01254 311 300, Fax 01254 433 252, Email [email protected]

PLEASE ENSURE THAT THE EMPLOYEE HAS BEEN MADE AWARE OF THE REASON FOR THIS REFERRAL.

FAILURE TO PROVIDE ALL NECESSARY INFORMATION MAY CAUSE DELAY IN ARRANGING REFERRAL APPOINTMENT Referral for Occupational Health Consultation Please note appointments cannot be made without a correctly and fully completed referral form and it is the referring manager’s duty to ensure the employee is fully aware of the reason for referral.

Employee Employee Name Location Division (circle appropriate) Therapies Service Lifestyle Nursing Unplanned Care Primary Care Operations & Performance Estates Human Resources Finance Quality & Governance

Employee Details - Occupational health will return the form if this section is not fully completed

Full Name: Date of Birth Home Address (Including Postcode) Job Title Employment Start Date Telephone Number Mobile Number Working Hours: Mon Tue Wed Thurs Fri Sat Sun Shift pattern Days / Nights / Rotating* * delete

D:\Docs\2018-04-12\0e31c0025e58e81be40c744e4db2ca68.doc Reason for Referral Long term sickness absence (at 4 weeks or expected to be continuous sickness)

Short term sickness (frequent or sporadic sickness -please attach details to referral)

Health Surveillance (State type of surveillance required)

Other Management Concerns(Please append details to referral)

Absence History No absence

Date absence began

Reason for absence (Please take absence reason directly from Fit Note)

Has the employee returned to work? (If yes please give date and any modified duties)

Advice required from Occupational Health: (Please only tick boxes required) What is the employee's current state of fitness for work? Likely date of return to work? What effect will this condition have on the employee's ability to carry out his/her current position? Are there any modifications/adjustments which would alleviate the condition or aid rehabilitation? Are there any particular duties the employee will not be able to carry out? Is the condition likely to reoccur in the future? Is the employee’s condition likely to be covered by the Disability Discrimination Act? Specific information/advice sought: Please append details overleaf

The more information you provide, the more thorough we are able to be in dealing with the referral.

Referring Manager Details: Name of Referring Manager Job Title of Referring Manager Location

Office Telephone Number Work Mobile Telephone Number E-Mail address

D:\Docs\2018-04-12\0e31c0025e58e81be40c744e4db2ca68.doc Name of Deputy Manager Job Title of Deputy Manager Location

Office Telephone Number Work Mobile Telephone Number E-Mail address

Notes 1. Failure to provide all necessary information will impact on the outcome of the appointment. 2. Please ensure you are familiar with the PAM Consultation Policy. 3. We encourage managers to have a discussion with the OH clinician. Please indicate your instructions and ensure your availability on the number/s provided. Client Briefing Instructions

I Do / Do Not require a briefing call from the clinician

I Do /Do Not require a de-brief call from the clinician

***If you indicate a call is required please ensure you are available at the appointed time/s on the numbers provided**

Additional Manager Comments

Suggested prompts for consideration:

- Consider background information needing to be shared - Consider for ill-health retirement (pension) - Consider for retirement on medical grounds (non pension) - Sickness absence history - Reasonable adjustments - Redeployment appropriate – temp/perm - Likely timescale for employee to return to work - Consider any other contributory factors you may be aware of i.e. personal/carer responsibilities

D:\Docs\2018-04-12\0e31c0025e58e81be40c744e4db2ca68.doc Please continue onto separate sheet

Manager Signature: ...... Date: ......

Employee Consent

(To be signed/verbally agreed during the first appointment with People Asset Management Clinician)

I understand that relevant information regarding my health/work will be passed to the referring manager, deputy manager and HR and that my Occupational Health record is stored confidentially by PAM OH Solutions.

...... Signature of Referred Employee

D:\Docs\2018-04-12\0e31c0025e58e81be40c744e4db2ca68.doc