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
Company Name*
Company Address*

Street Address

Street Address Line 2
CityState / ProvincePostcode
Contact/Representative Name*
Role*
Email*
example@example.com
Telephone*

Area CodePhone Number
Employee Details
Full Name*
Job Title*
Department / Location*
Employment Status*
Length of Service*
Reason for Referral
Reason for Referral to Occupational Health*
Date Issue First Arose*

DayMonthYear
Date
Recent Change or Trigger
Impact on Work
Attendance Impact*
Performance Impact*
Behaviour Impact (if relevant)*
YesNoNot Applicable
Absence Record
YesNoNot Applicable
If Yes, Since When?*

DayMonthYear
Date
Number of Absences in Last 12 Months*
Total Days Lost (if known)*
Expected Return to Work Date*

DayMonthYear
Date
Current Work Status
YesNoNot Applicable
YesNoNot Applicable
YesNoNot Applicable
Current Restrictions or Limitations*
Adjustments and Support
YesNoNot Applicable
Details of Adjustments*
EffectiveNot Effective
YesNoNot Applicable
Job Role Information
Main Duties and Responsibilities*
YesNoNot Applicable
YesNo
YesNoNot Applicable
YesNoNot Applicable
YesNoNot Applicable
YesNoNot Applicable
Physical Demands of the Role*
Mental/Cognitive Demands of the Role*
Environmental Factors (e.g. noise, temperature, hazards)*
Working Pattern
Working Hours*
Shift Pattern (if applicable)*
Overtime or Irregular Hours (if applicable)*
Workplace Risks and Safety
YesNoNot Applicable
YesNoNot Applicable
YesNoNot Applicable
YesNoNot Applicable
YesNoNot Applicable
Relevant Background Information
Relevant Health Information (as known)*
YesNoNot Applicable
Fit Note Details*
YesNoNot Applicable
Summary/Outcome of Previous Referrals*
Management Actions to Date
Actions Taken to Support Employee*
YesNoNot Applicable
Questions for Occupational Health
Questions for Occupational Health*
Next Steps / Administration
Proposed Assessment Type (if known)*
Deadlines or Time Sensitivities*
Declaration
I confirm that the information contained within this referral form is accurate, complete, and to the best of my knowledge a true reflection of the employee's current circumstances. I further confirm that I am authorised to submit this referral on behalf of the organisation and that written, signed consent has been obtained from the employee prior to submission. I understand that this form and any subsequent occupational health report may be shared with the employee in accordance with their consent and applicable data protection legislation.*

I have read and confirm the above statement
Completed By*
Role*
Date*

DayMonthYear
Date
Signature*
Should be Empty:

Occupational Health Case Management Referral Form

Employer Details

Employee Details

Reason for Referral

Impact on Work

Absence Record

Current Work Status

Adjustments and Support

Job Role Information

Working Pattern

Workplace Risks and Safety

Relevant Background Information

Management Actions to Date

Questions for Occupational Health

Next Steps / Administration

Declaration