ࡱ>  bjbj:0:0 4XZgXZgA ffN*fB NNNN|@)))))))$,j/B)]A"AA)ffNN9*!!!A"f8NN)!A)!!:u&,&Nfccp& q)*0N*&R00&&\0Y'AA!AAAAA))6AAAN*AAAA0AAAAAAAAA X ,:  Bangor University Occupational Health Referral Form  Manager s InformationName:Miss Kerry BloggsAcademic School/Service Department: FORMTEXT     Student Services Contact Number: FORMTEXT      1234Date of Referral: FORMTEXT      31/01/22Employee InformationName: FORMTEXT      Julie PictonAddress: FORMTEXT      123 West Avenue, Bangor, Gwynedd LL57 2DGDate of Birth: FORMTEXT      19/01/1965Contact Phone Number: FORMTEXT      07*******66Email address:J**** @bangor.ac.ukJob Title: FORMTEXT      AdministratorHours of work (per week):36.25Date the employee was made aware of referral: FORMTEXT      31/01/22Date started in post:2019Please 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:Jade Luke Reason for Referral & Specific Advice RequiredLong Term (including advice on phased return to work): Intermittent Absence: In work (Welfare Referral): xImmediate Referral (Stress/Musculoskeletal):  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.Julie commenced work in Student Services in 2019 prior to the pandemic. Julie appears to be struggling a little with her wellbeing at present and has become tearful during group staff training and has referenced feeling isolated due in part to working from home during Covid-19. Julie is struggling with anxiety which stems from the risk of Covid-19 to her vulnerable mother who she lives with. Julie has also expressed that she does not feel confident with certain aspects of her role and feels overwhelmed at times with the volume of work. I have met with Julie separately and discussed assigning an experienced member of the team to mentor. We have undertaken a workplace stress risk assessment with Julie. Please see attached. The team are also implementing a regular informal catch-up meeting over teams to help with feelings of isolation and getting to know the team better which has been met positively by Julie. Please can you outline any further support that can be utilised to assist Julie during this difficult time  **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?  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?8In your professional opinion is the health problem likely to meet the criteria for disability as defined by the Equality Act 2010?  + + 9Should the individual be considered for redeployment on medical grounds?10Should 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 K Bloggs. Date 31/01/22....  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Telephone contact, email contact or meeting with individual. Please include dates. 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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