Occupational Health Case Management Referral Form

  • Occupational Health Case Management Referral Form

    This form is used to refer an employee for an occupational health assessment and must be completed by an authorised employer representative prior to any assessment being arranged. It is essential that all sections are completed accurately and in full, providing clear, factual, and objective information regarding the employee's job role and responsibilities, the clinical or work-related reason for referral, the nature and duration of any absence or presenteeism, and the specific impact the health condition or concern is having on the employee's ability to fulfil their duties. This form must not be completed or submitted unless written, signed consent has been obtained from the employee - either directly by the employer or by Biofit Health - prior to submission.

  • Employer Details

  •  -

  • Employee Details

  • Reason for Referral

  • Date Issue First Arose*
     - -

  • Impact on Work

  • Safety Concerns for Employee or Others*

  • Absence Record

  • Is the Employee Currently Off Work?*
  • If Yes, Since When?*
     - -
  • Expected Return to Work Date*
     - -

  • Current Work Status

  • Is the Employee Currently Fit for Work?*
  • Is the Employee Currently on Adjusted Duties?*
  • Is the Employee Currently Not Fit for Work?*

  • Adjustments and Support

  • Workplace Adjustments in Place*
  • Effectiveness of Adjustments*
  • Employee Requested Adjustments*

  • Job Role Information

  • Role Includes Manual Handling*
  • Role Includes Prolonged Sitting/Standing*
  • Role Includes Driving*
  • Role Includes Working at Height*
  • Role Includes Use of Machinery*
  • Role Includes High Concentration / Decision-Making*

  • Working Pattern

  • Workplace Risks and Safety

  • Risks Associated with Employee Continuing in Role*
  • Role Involves Safety-Critical Duties*
  • Risks to the Employee*
  • Risks to Colleagues*
  • Risks to Customers / Service Users*

  • Relevant Background Information

  • Employee Provided Fit Note*
  • Previous Occupational Health Referrals*

  • Management Actions to Date

  • Formal Processes Initiated (e.g. absence management, capability)*

  • Questions for Occupational Health

  • Next Steps / Administration

  • Declaration

  • Date*
     - -
  • Should be Empty: