ࡱ>  bjbj:0:0 4XZgXZg ff*fJDDDDmt<G)I)I)I)I)I)I)$v,,/Bm)]}"m)ffDD9) "f8DDG) G) :&,&DX"?jG& 3))0*Q&Rn0n0&&\n0&4 m)m)*n0 X ,:  Bangor University Occupational Health Referral Form  Manager s InformationName: Betty Bloggs Academic School/Service Department: Corporate ServicesContact Number: FORMTEXT      1234Date of Referral: FORMTEXT      31/01/22Employee InformationName: FORMTEXT      Minnie JonesAddress: FORMTEXT      Ty Awelog, Menai Bridge, AngleseyDate of Birth: FORMTEXT      01/06/1970Contact Phone Number: FORMTEXT      07*******66Email address:M**** @bangor.ac.ukJob Title: FORMTEXT      Senior Clerical OfficerHours of work (per week):0.6FTEDate the employee was made aware of referral: FORMTEXT      31/01/22Date started in post:1992Please 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:Catherine Hughes Reason for Referral & Specific Advice RequiredLong Term (including advice on phased return to work): Intermittent Absence: In work (Welfare Referral): Immediate Referral (Stress/Musculoskeletal): x 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.Minnie has submitted a fit note this week noting stress at work. Early contact has been made with Minnie to gain an understanding of her stressors in the workplace. Minnie has struggled with difficulties communicating with a colleague in a shared office regarding working conditions such as the office temperature and noise levels whilst undertaking telephone work. This has escalated and caused Minnie to feel too anxious to attend the workplace. Minnie has also identified that she is having some personal difficulties at home and coupled with this has struggled to maintain a good work life balance as her workload has also been identified as being high. A stress risk assessment is underway and additional control measures to manage workload have already been implemented. Some signposting and support for Minnie would be welcomed and further guidance regarding any adjustments in the workplace that can ensure comfort levels in the office can be maintained for Minnie would be very much appreciated.  **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? x 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?x8In your professional opinion is the health problem likely to meet the criteria for disability as defined by the Equality Act 2010? x + + 9Should the individual be considered for redeployment on medical grounds?x10Should 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 B Bloggs. Date 31/01/22....  Checklist of attachments:1Sickness Absence record (previous 12 months)x2Job Descriptionx3Any other relevant information please identify 4Details of last contact with the Individual if absent from work e.g. Telephone contact, email contact or meeting with individual. 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