ࡱ>  ثbjbj:0:0 4XZgXZg ff)fJ VVVV| @((((((($,.B )]I"II )ffVV9j)] ] ] I.f8VV(] I(] ] :%,W&V༪wv% ()0)&R00W&W&\0& II] IIIII ) )III)IIII0IIIIIIIII X ,:  Bangor University Occupational Health Referral Form  Manager s InformationName: Betty Bloggs Academic School/Service Department: FORMTEXT     Campus Services Contact Number: FORMTEXT      1234Date of Referral: FORMTEXT      31/01/22Employee InformationName: FORMTEXT      Mickey MouseAddress: FORMTEXT      17 High Street, LLanberis, GwyneddDate of Birth: FORMTEXT      01/05/1986Contact Phone Number: FORMTEXT      07*******66Email address:M**** @bangor.ac.ukJob Title: FORMTEXT      Multi Skilled Task OperativeHours of work (per week):0.8FTEDate the employee was made aware of referral: FORMTEXT      31/01/22Date started in post:2012Please indicate the preferred method of contact with the individual: Mobile  FORMCHECKBOX  Telephone  FORMCHECKBOX  Email  FORMCHECKBOX  Letter  FORMCHECKBOX Please indicate the individuals preferred method of assessment: Face to Face  FORMCHECKBOX  Teams (online video)  FORMCHECKBOX  Telephone  FORMCHECKBOX  HR Manager InformationFull Name:Catherine Hughes Reason for Referral & Specific Advice RequiredLong Term (including advice on phased return to work): xIntermittent Absence: xIn work (Welfare Referral): Immediate Referral (Stress/Musculoskeletal): x Management Contact: Details of last contact with staff member if on long term sickness absence:  Referral Details It is essential you provide as much background information as possible about why you are referring the employee, which may include length and reason for absence/ absence history/ dates and details of the Fit Notes/ the nature of the employees role and the impact the condition appears to be having on their ability to perform their duties/ what adjustments have already been put in place/ what support has been offered. If appropriate to the referral, please include details of any formal management processes the employee is currently involved in.Mickey has been experiencing a back problem for several years which has caused intermittent absences in the past Please see attached sickness absence history. Mickey notified me of his sickness absence on 30/11/21 and has been absent from work ever since. Mickey has been undertaking physio and his physio has recommended further medical investigation through MRI scan and neurology referral. There is a long waiting list and Mickey does not have any timescales to be seen. I have kept in contact with Mickey on a fortnightly basis and each time we speak Mickey is hopeful that he will return at the end of each fit note. Unfortunately, this has not been the case to date. Please can you outline any adjustments that may be needed to facilitate a sustained and swift return to work. The role is manual in nature; However, Mickey does have some administration skills that may be utilised on a temporary basis within the department. Is there any additional equipment that would assist Mickey in the workplace? Further signposting for Mickey and guidance to support his safe return to work is appreciated. **Please tick all the questions which you would like Occupational Health to answer.** (please ensure you refer to the guidance notes when completing this section)1What is the likely timescale for recovery and/or when do you anticipate a return to work? 2Is there an underlying medical condition affecting this individuals performance or attendance at work? x 3Are they fit to carry out the full range of duties of their current role? x 4Are there any short-term adjustments to the role/environment that would help facilitate rehabilitation or an early return to work x5Are there any reasonable permanent adjustments to the role or environment that can be recommended? x6Is there further requirement for medical support or intervention? 7Will they be able to offer a regular and efficient service in the future or is this health problem likely to recur or affect future attendance?x8In your professional opinion is the health problem likely to meet the criteria for disability as defined by the Equality Act 2010? x + + 9Should the individual be considered for redeployment on medical grounds?x10Should the individual be considered for Ill Health Early Retirement? Confirmation of discussion with individual being referred:I can confirm that the individual has been made aware of this referral and a copy has been provided to them ahead of being referred to Occupational Health Managers Signature B Bloggs. Date 31/01/22....  Checklist of attachments:1Sickness Absence record (previous 12 months)x2Job Descriptionx3Any other relevant information please identify 4Details of last contact with the Individual if absent from work e.g. Telephone contact, email contact or meeting with individual. 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28/01/2022 For Occupational Health Service only:Date received in OHDate of OH assessmentDate report sent from OH to employeeDate report sent from OH to Manager / HRGP/ Specialist report requested?Yes / NoDate Sent: Date Received: Date Reviewed: Notes  FORMTEXT  Guidance for managers:- Please attach a copy of the employees job description and sickness record (if applicable) and forward the completed referral to Jade Luke in Human Resources. Please include as much information as you possibly can. The quality of the advice and the report will largely depend on the information provided by the referring manager in the first instance. It is a requirement to inform the employee that a referral is being made and share with them the content of this document. This will support OH in maximising the effectiveness of their meeting with your member of staff. Further guidance is available in the OH Referral Guidance Notes. 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