Occupational Health Assessment referral letter template

I am writing to refer [Employee's Name], an employee of [Company Name], to you for an assessment of their health status and any potential work-related issues.

[Employee's Name] has been experiencing [brief description of health concerns or issues, if known]. Due to the nature of their role within our organisation and our commitment to ensuring the well-being and safety of all employees, we believe it is essential for them to undergo a thorough evaluation.

Please conduct a comprehensive assessment of [Employee's Name]'s health status, with a focus on any potential occupational hazards or concerns that may impact their ability to perform their job safely and effectively. Additionally, we would appreciate your insights and recommendations regarding any necessary accommodations or adjustments that may be required to support [Employee's Name] in their role.

[Employee Name] has provided written consent for us to request this assessment, whch I have enclosed.

Enclosed with this letter are relevant medical records and any additional information that may assist you in your assessment. Please see the followng details:

Employee Details

• Employee Name:

• Date of Birth:

• Employee Address:

• Employee Mobile No:

• Employee Email:

• Job Title:

• Length of Service:

• Company:

• Company Address:

• Referring Manager:

• Manager contact no:

• Manager Email:

• HR Manager:

• HR Contact no:

• HR Email:

• Who report to be sent to:

• Date of referral:

• PO number if required:

Job Description

Please summarise the job role, detailing main tasks, hazards, and hours of work.

Reason for Referral

Please delete those not applicable:

• Recurrent short spells of absence causing commercial concern

• Prolonged sickness and/or absence

• Return to work assessment

• Fitness for Work

• Before Job Transfer / Modification / Promotion

• Concerns for work performance

• Fitness to attend disciplinary meeting

• Suspected Alcohol or Drug Misuse

• Other - Please give details below:

Details of Current Problem

• Health condition / diagnosis (if known):

• Observed impact on job role (if relevant):

• Adjustments offered/actions taken to address problems outlined in the referral:

• Date of current absence (if relevant):

• Sickness record for the last 24 Months if relevant (include dates and reason for absence):

• Performance issues (attendance, timekeeping, motivation)? If yes give details:

• Disciplinary warnings in force in relation to performance? If yes give details:

• Has the employee raised any concerns they have in the workplace? If yes give details:

• Please attach GP / Specialist Reports / previous OH reports if appropriate.

Confirmation of Employee Awareness

Please confirm the employee has been given a copy of this referral: [Yes/No]

Questions for the OH Professional

Please delete those not applicable:

1. Is there a health condition present and is it likely to be permanent, fluctuating or resolvable?

2. Are there any work-related aspects to the health problem?

3. Is the employee fit to undertake normal duties of their current role?

4. When is a return to work likely?

5. Are there any suggested adjustments or supportive measures to help the employee?

6. In your medical opinion, is the employee likely to be classed as disabled under the Equality Act 2010?

7. Is the employee fit to attend a disciplinary/sickness meeting? (please delete as appropriate)

8. Is a further OH review recommended?

9. Additional Questions:

Thank you for your attention to this matter. If you require any further information or assistance, please do not hesitate to contact me at [Your Contact Information].