ࡱ> qunopg bjbjJJ 8h( j( jI6_MRR555III8] LI&c" .(..'/ 11\120aaaaaaa$exha5a20" 1a2a2a.'/b888a2R8.5'/_ 8a2a88nXd[.@0O\P#2Y _b0&cZDiM3Di@[[JDi5\da2a28a2a2a2a2a2aa'6ta2a2a2&ca2a2a2a2Dia2a2a2a2a2a2a2a2a2RY :  Information for managers Guidance on the use of OH Referrals is available at  HYPERLINK "http://www.imperial.ac.uk/occupational-health/workplace-wellbeing/staff-referral/" http://www.imperial.ac.uk/occupational-health/workplace-wellbeing/staff-referral/ and in the HR Sickness Absence Policy at  HYPERLINK "/human-resources/leave/sickness-absence/" /human-resources/leave/sickness-absence/. If you need further advice on whether referral for assessment is appropriate, contact the HR Hub or an OH Advisor at Occupational Health. Under Reason for referral please provide sufficient information, including information on job performance where this is an issue, for the OH Advisor carrying out the assessment to understand why a medical opinion is being sought at this time. You should also indicate any specific questions you would like addressed in the report. Note that it is not possible to comment on whether past absences on sickness grounds were justified. The member of staff must be given an opportunity to read the completed form before being asked to give their consent for an assessment. The staff member should sign Section B to confirm their agreement. The completed referral form must be submitted to Occupational Health by email  HYPERLINK "mailto:occhealth@imperial.ac.uk" occhealth@imperial.ac.uk or post before an appointment can be arranged. Assessments are carried out by either a qualified OH Advisor or the College OH Physician. On receipt of a completed form, they are triaged by a senior OH Advisor and the case allocated to the most appropriate clinician. Occupational Health will contact the member of staff directly and schedule a face-to-face or remote appointment. Details of the appointment will also be sent to the person making the referral. If the person does not attend an appointment OH will inform/notify the person who has made the referral Reports are usually provided within 2 working days of an assessment or within 5 days if the member of staff requests to view the report and consent to its release before it is supplied to the referrer. If a longer delay is anticipated, the OH Advisor will advise the referrer of this. A copy of the definitive report is sent to the member of staff, the referrer and to the HR Hub where it will be attached to their employment record, if required the nominated HR advisor for that department will have access to it from this location. Reports should be treated as sensitive special category data. The fitness assessment and recommendations on adjustments to accommodate health problems and conditions can be shared with others on a need to know basis to facilitate effective decision-making on implementing recommendations on support and adjustments. An OH report does not usually include confidential medical information. Where it does, the specific consent of the member of staff should be sought before such information is divulged to others. Clinic Address Access information Occupational Health Level 4, Sherfield Building South Kensington Campus tel. 020 7594 9401  HYPERLINK "mailto:occhealth@imperial.ac.uk" occhealth@imperial.ac.uk Occupational Health is located on the 4th floor of the Sherfield Building. Access the Sherfield Building. Access is via the east side of the Sherfield walkway next to Dalby Court. The route from the College main entrance provides step-free access. Allow 15 minutes if walking up from South Kensington tube station. Wheel chair users, or anyone unable walk more than 100 metres without assistance can contact the OH Office on 020 7594 9401 to arrange an alternative shorter access route. Please telephone 020 7594 9401 if you think you will need assistance or have concerns about accessibility (e.g. disabled parking arrangements). Section A: Referral information 1.1 Personal details Member of staffs full name Last name FORMTEXT       FORMTEXT   First name  FORMTEXT       FORMTEXT   Title  FORMTEXT        FORMCHECKBOX  Mr  FORMCHECKBOX  Mrs  FORMCHECKBOX  Ms  FORMCHECKBOX  Dr  FORMCHECKBOX  Prof  FORMCHECKBOX  Mx  FORMCHECKBOX Other  FORMTEXT       CID  FORMTEXT       DOB  FORMTEXT       Age  FORMTEXT       Home address  FORMTEXT       Home telephone number  FORMTEXT       Home email (if available)  FORMTEXT       Work telephone number  FORMTEXT       Work email  FORMTEXT       Date of starting employment with Imperial College  FORMTEXT       Date of appointment to present post (if different)  FORMTEXT       Does the staff member speak English?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If no, what language is spoken?  FORMTEXT       1.2 Job details Job title  FORMTEXT       Department/ Division  FORMTEXT       Section  FORMTEXT       Campus  FORMDROPDOWN  Work location  FORMTEXT       Usual hours of work  FORMTEXT       Work pattern  FORMCHECKBOX  Full-time  FORMCHECKBOX  Part-time  FORMCHECKBOX  Jobshare Overtime  FORMCHECKBOX  None  FORMCHECKBOX  Occasional  FORMCHECKBOX  Regular 1.3 Job demands Tick all relevant boxes Physical demands Work hazards Regular/ frequent exposure to: Work location Other demands  FORMCHECKBOX  Deskwork  FORMCHECKBOX  Standing  FORMCHECKBOX  Lifting or carrying*  FORMCHECKBOX  Computer work  FORMCHECKBOX  Operating machinery  FORMCHECKBOX  Driving *  FORMCHECKBOX  Noise *  FORMCHECKBOX  Dust or fumes *  FORMCHECKBOX  Chemicals *  FORMCHECKBOX  Biological hazards *  FORMCHECKBOX  Work at heights*  FORMCHECKBOX  Work in confined space *  FORMCHECKBOX  Fieldwork *  FORMCHECKBOX  Safety critical work*  FORMCHECKBOX  Office  FORMCHECKBOX  Laboratory  FORMCHECKBOX  Lecture theatre  FORMCHECKBOX  Workshop  FORMCHECKBOX  Outdoors *  FORMCHECKBOX  Mobile around site  FORMCHECKBOX  Offsite *  FORMCHECKBOX  Other *  FORMCHECKBOX  Teaching  FORMCHECKBOX  Demonstrating  FORMCHECKBOX  Clinical work  FORMCHECKBOX  Management of staff  FORMCHECKBOX  Travel abroad *  FORMCHECKBOX  Other significant demand* Further details, particularly for asterisked (*) items:  FORMTEXT       1.4 Reason for referral Why is the person being referred for an assessment at this time? Tick all appropriate boxes  FORMCHECKBOX  Concern over attendance  FORMCHECKBOX  Concern over performance  FORMCHECKBOX  Concern over welfare/well-being  FORMCHECKBOX  Safety assessment  FORMCHECKBOX  Assessment following an accident at work  FORMCHECKBOX  Advice to support return to work  FORMCHECKBOX  Disability assessment  FORMCHECKBOX  Fitness for re-deployment if alternative role is available  FORMCHECKBOX  Consideration for medical retirement  FORMCHECKBOX  Other please specify:  FORMTEXT       Details:  FORMTEXT       Where the reason for referral includes work stress, the Imperial Stress Risk Assessment procedure needs to be completed,HYPERLINK "https://www.imperial.ac.uk/health-and-wellbeing/stress-and-wellbeing/" \o "https://www.imperial.ac.uk/health-and-wellbeing/stress-and-wellbeing/" \t "_blank"Workplace Stress and Wellbeing and the outcome and agreed mitigations must be included in the referral to occupational health. Has the person been referred for assessment before?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If so, when?  FORMTEXT       If this relates to an ongoing concern, what additional information is required?  FORMTEXT       Have any of the following workplace adjustments been put in place to support this person?  FORMCHECKBOX  Regular working from home days  FORMCHECKBOX  Occasional working from home days  FORMCHECKBOX  Adjusted deadlines  FORMCHECKBOX  Adjusted duties  FORMCHECKBOX  Specialist equipment  FORMCHECKBOX  Additional support  FORMCHECKBOX  Work on another site  FORMCHECKBOX  Other Are there concerns about these adjustments?  FORMTEXT       This referral has been initiated by  FORMCHECKBOX  Line manager  FORMCHECKBOX  Human Resources  FORMCHECKBOX  Equality Diversity & Inclusion team 1.5 Information requested Please advise on the following issues: Is there an underlying health problem that may affect attendance or performance? If so, when is it likely to be resolved? If and when the person returns to work, will they be able to carry out the duties detailed on this form and their job description? Are there any adjustments to duties, equipment or work conditions which may assist the return to work and/or enable the person to do their job? Is the person permanently unfit Other issues as detailed below:  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Details  FORMTEXT       1.6 Current medical issuesIs the member of staff currently on sick leave? FORMCHECKBOX  Yes  FORMCHECKBOX  NoWhen does the current  Fit Note expire? FORMTEXT      What is the reason given for the most recent absence? 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Your consent is required for this. All information you provide at an OH assessment is held in medical confidence. The report provides an opinion on the effects of any health problems or disability on your work and advises on support measures/ adjustments that could help you. Specific medical details are only included if it will be of benefit to you for your manager to be aware of them and if you have specifically agreed to this. You do not have to agree to this assessment. However, if you do not agree and your attendance, performance or conduct is causing concern, then the matter may have to be taken forward without the benefit of medical advice. At the end of the assessment, the OH Advisor will discuss their conclusions with you and outline the content of their report. The Advisor will ask you to confirm that you consent for the report to be provided. You can, if you wish, arrange to see a copy of the written report before doing so and have 48 hours to respond to this. I agree to attend an Occupational Health assessment Print Name:  FORMTEXT       Date:  FORMTEXT       Reports from your own doctor If the OH Advisor needs to obtain additional information from your doctor, specialist or some other person who has been treating you to complete your assessment, then they will discuss this with you and ask you to sign an additional consent form to obtain this. The OH Advisor will explain to your rights under the Access to Medical Reports Act 1988. Data Protection Information The information that you supply on this questionnaire will be held in confidence by the Occupational Health as part of your Occupational Health record, please refer to the Occupational Health Privacy Notice:  HYPERLINK "http://www.imperial.ac.uk/occupational-health/privacy-notice" www.imperial.ac.uk/occupational-health/privacy-notice Section C: Manager s checklistI have explained to the member of staff the purpose of this referral FORMCHECKBOX The member of staff has had the opportunity to view this form and consent prior to attendance FORMCHECKBOX   I enclose:  FORMCHECKBOX  The person s job description FORMCHECKBOX  Accident report (if relevant) FORMCHECKBOX  Any other relevant documents Name of person making the referral FORMTEXT      Position FORMTEXT      Telephone number FORMTEXT       Email  FORMTEXT      Named HR Representative (if relevant) FORMTEXT      Date of completion  FORMTEXT           ( Imperial College London Occupational Health  PAGE 6/ NUMPAGES 6 Aug 2026 Referral for Occupational Health Assessment, Advice and Management Report (*,.0LNPRTprtvxr]]]]](jhvhxcjCJU^JmHnHu#jhvhxcjCJU^JjhvhxcjCJU^JhvhxcjCJ^J#j@hvhxcjU^JaJ#jʧhvhxcjU^JaJ#jThvhxcjU^JaJjhvhxcjU^JaJ#jަhvhxcjU^JaJhvhxcj^JaJ!Rv<`Fn(PxFfѸFf{ $9DIfgdxcjFf%$$9DIfa$gdxcj  *,.02468:<>Z\^`b~޾޾޾޾޾n#j4hvhxcjU^JaJhvhxcj^JaJjhvhxcjU^JaJ#jhvhxcjCJU^J#j,hvhxcjCJU^JhvhxcjCJ^J(jhvhxcjCJU^JmHnHujhvhxcjCJU^J#jhvhxcjCJU^J&~ ӯӤnnnnn\nnnnn#jhvhxcjCJU^J(jhvhxcjCJU^JmHnHu#jnhvhxcjCJU^JjhvhxcjCJU^JhvhxcjCJ^J#jhvhxcjU^JaJ#j hvhxcjU^JaJhvhxcj^JaJjhvhxcjU^JaJ#jhvhxcjU^JaJ$ 468:<>@BDFH\^`bdfhjlnpt𾾾𾾾坒n\#jvhvhxcjU^JaJ#jhvhxcjU^JaJ#jhvhxcjU^JaJhvhxcj^JaJjhvhxcjU^JaJ#jhvhxcjCJU^J(jhvhxcjCJU^JmHnHu#jhvhxcjCJU^JhvhxcjCJ^JjhvhxcjCJU^J$ "$&(*>@BDFHJLNPRfhjlnprtvxzȹȧȹȀȹnȹ#jػhvhxcjCJU^J#jNhvhxcjCJU^J(jhvhxcjCJU^JmHnHu#jĺhvhxcjCJU^JjhvhxcjCJU^JhvhxcjCJ^J#jhvhxcjU^JaJhvhxcj^JaJjhvhxcjU^JaJ+  *,.024H޾n\޾#jBhvhxcjU^JaJ#j̽hvhxcjU^JaJ#jVhvhxcjU^JaJ#jhvhxcjU^JaJhvhxcj^JaJjhvhxcjU^JaJhvhxcjCJ^J(jhvhxcjCJU^JmHnHujhvhxcjCJU^J#jPhvhxcjCJU^J  02Z>bd(LpFfFf} $9DIfgdxcjFf'$$9DIfa$gdxcjHJLNPRTVXZ\prtvxz|~޾޾޾޾޾޾޾yjhvhxcjU^JaJ#jhvhxcjCJU^J#j.hvhxcjCJU^J#jhvhxcjCJU^JhvhxcjCJ^J(jhvhxcjCJU^JmHnHujhvhxcjCJU^J#jhvhxcjCJU^J+8:<>@\^`bdfz|~r]]]]](jhvhxcjCJU^JmHnHu#jphvhxcjCJU^JjhvhxcjCJU^JhvhxcjCJ^J#jhvhxcjU^JaJ#j"hvhxcjU^JaJ#jhvhxcjU^JaJjhvhxcjU^JaJ#j6hvhxcjU^JaJhvhxcj^JaJ!"$&(*F޾޾޾޾޾n#jhvhxcjU^JaJhvhxcj^JaJjhvhxcjU^JaJ#jhvhxcjCJU^J#jhvhxcjCJU^JhvhxcjCJ^J(jhvhxcjCJU^JmHnHujhvhxcjCJU^J#jhvhxcjCJU^J&FHJLNjlnprtӯӤnnnnn\nnnnn#jPhvhxcjCJU^J(jhvhxcjCJU^JmHnHu#jhvhxcjCJU^JjhvhxcjCJU^JhvhxcjCJ^J#jhvhxcjU^JaJ#jxhvhxcjU^JaJhvhxcj^JaJjhvhxcjU^JaJ#jhvhxcjU^JaJ$  $&(*,.02468TVXZ\xz|~濿濿o]#jhvhxcjU^JaJ#jXhvhxcjU^JaJ#jhvhxcjU^JaJhvhxcj^JaJjhvhxcjU^JaJ#jRhvhxcjCJU^J(jhvhxcjCJU^JmHnHu#jhvhxcjCJU^JjhvhxcjCJU^JhvhxcjCJ^J$6Z~ $IfgdcSK$  9r $IfgdcSFf)$$9DIfa$gdxcj $9DIfgdxcj @t t  jthj¹~qqqcYhu_pCJ^JaJhH*hcS5CJ^JaJhH*hu_pCJ^JaJhH*h%CJ^JaJhH*hcSCJ^JaJhcS5CJ^JaJnH tH #hvhcS5CJ^JaJnH tH hvhcS^J hcS^JhvhxcjCJ^J#jDhvhxcjU^JaJhvhxcj^JaJjhvhxcjU^JaJ  jjl4znnnnbbY $IfgdcS $$Ifa$gdcS $$Ifa$gdu_pkd$IfK$L$l:((  t ff0(22 944 lap ffytujl "$&(*2468:<>ĮҖĀҖܴڴڰ°°°°5Cϴ(5Cϴ󳦳5C*H*󳦳6C/H*󳦳6CԱ*H*󳦳6CH*󳦳6C$H*󳦳6CH*󳦳5C((䴳"468:<>@B|:<t $$Ifa$gdB; $$Ifa$gdcS$$Ifa$gd]( z|:<t.0\^{iZiiO> jhvhcS6CJU^JhvhcSCJ^JhcS5CJ^JaJnH tH #hvhb5CJ^JaJnH tH #hvhB;5CJ^JaJnH tH #hvhcS5CJ^JaJnH tH %jhH*hcS0JCJU^JaJhH*hcS0JCJ^JaJ!jhH*hcSCJU^JaJhH*hcS5CJ^JaJhH*hcSCJ^JaJ#h](hcS5CJOJQJ^JaJ\ $IfgdLrkd$$Ifl() t0z+y22 944 laytu\^ }mmmmdx$IfgdcSkdR$$Ifl()  t ff0z+y22 944 lap ffytu  t:<>ôâ󙍙rÍ`Ä#jhvhcSCJU^J#jhvhcSCJU^JhvhcS^JhvhcS5CJ^JhcS5CJ^J#j~hvhcSCJU^JjhvhcSCJU^JhvhcSCJ^J jhvhcS6CJU^J&jhvhcS6CJU^JhvhcS6CJ^J"VMMMMM $IfgdcSkd$$Ifl\&'*6^ t0z+2944 laytuBDnaaaa x$IfgdcSkd$$IflKFL'*=H  t0z+    44 laytu@BDF*ӿxxxxxdxxxxx&jhvhcS6CJU^J+jhvhcS6CJU^JmHnHu&jhvhcS6CJU^J jhvhcS6CJU^JhvhcS5CJ^JhvhcS6CJ^JhcSCJ^JhvhcSCJ^JjhvhcSCJU^J#jhvhcSCJU^J#DFnaa x$IfgdcSkd $$IflKFL'*=H  t0z+    44 laytu|oo x$IfgdcSkdJ$$Ifl0(< t0z+y2944 laytu>|oo x$IfgdcSkd$$Ifli0(< t0z+y2944 laytu*,.02468:<>@NPdfhjlnprtvx۹ۭۭۭpchvhcSCJ$^JaJ$&jhvhcS6CJU^JhcShcS5CJ^JhcS5CJ^J&jhvhcS6CJU^JhvhcS6CJ^JhvhcS5CJ^J+jhvhcS6CJU^JmHnHu jhvhcS6CJU^J&j`hvhcS6CJU^J&>@Nv|oo x$IfgdcSkd$$Ifl0(< t0z+y2944 laytuvx|oo x$IfgdcSkd$$Ifl0(< t0z+y2944 laytu>|oo x$IfgdcSkd<$$Ifl0(< t0z+y2944 laytu,.02468:<>@BDFHJLNPRTVXZ\^͹Ͱ|q||q|hXW0JmHnHu hfP0JjhfP0JU hfPCJ jhfPCJh)jh)Uhvh4^Jhvhb^J&jhvhcS6CJU^JhvhcS6CJ^J jhvhcS6CJU^JhvhcS5CJ^JhcS5CJ^J+>@DHJNPTVZ\|sqqqqqqqqhq  9r ' &gdbkdh$$Ifl0(< t0z+y2944 laytu 68BprϾsjhvh4^JhfP5B*CJOJQJphffhfP5B*CJaJphffh' 5B*CJaJphffhl,5B*CJaJphff h%h' 5B*CJaJphff h%hl,5B*CJaJphff h%hfP5B*CJaJphffhPThfP h0;CJ hcSCJ hxk-CJ h roCJ &gdb$a$gd' 61h/R :pg. 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