Employee Occupational Health Consent Form

Employee Occupational Health Consent Form

Please fill out your details and provide your consent by signing below.
Employee Full Name*

First NameLast Name
Home Address*

Street Address

Street Address Line 2
TownCountyPostcode
Job Title*
Employer Name*
Email Address*
example@example.com
Telephone Number*

Area CodePhone Number
Employee Consent to Occupational Health Referral and Information Sharing

I understand that my employer has proposed a referral to an Occupational Health Practitioner to obtain independent advice regarding my health in relation to my work.

I confirm that:
- I have been informed of the reason for this referral and have had the opportunity to ask questions.
- I understand that Occupational Health provides advice to my employer and does not make decisions regarding my employment.
- I understand that the assessment may involve discussing my health, work, and any relevant circumstances affecting my ability to carry out my role.
Consent to Assessment
I give my consent to be referred to and assessed by an Occupational Health Practitioner for the purposes of obtaining advice on my fitness for work and any recommended workplace adjustments.

Consent to Use and Processing of Information
I understand that, as part of this process, my personal and health information will be collected and processed in accordance with UK data protection legislation (including UK GDPR). This information will be used solely for the purpose of providing occupational health advice.

Consent to Release of Occupational Health Report
I understand that:
- Following my assessment, an Occupational Health report will be prepared.
- I may be offered the opportunity to review the report before it is shared with my employer.
- I have the right to request amendments to factual inaccuracies.
- I can withhold consent for the report to be released to my employer, although I understand this may limit my employer’s ability to make informed decisions regarding my employment.
I give my consent for the Occupational Health report to be shared with my employer.

Consent to Access Medical Information (if required)
Where necessary, I give my consent for the Occupational Health Practitioner to request further medical information from my GP or other treating practitioner. I understand that:
- My explicit consent will be sought before any such request is made.
- I have rights under the Access to Medical Reports Act 1988, including the right to view any report before it is shared and to request amendments to factual inaccuracies.
Voluntary Consent
I understand that:
- My participation in this process is voluntary.
- I may withdraw my consent at any time prior to the release of the Occupational Health report by notifying the Occupational Health provider.
Declaration
I confirm that I have read and understood this consent agreement and that I give my consent to the following:
Referral to an Occupational Health PractitionerAssessment by an Occupational Health PractitionerProcessing of my personal and health informationRelease of the Occupational Health report to my employerRequesting medical information from my GP or other healthcare provider (if required)
Employee Signature*
Date*

DayMonthYear
Date
Should be Empty: