ࡱ> '` ]bjbjLULU .?.? 0008hE5h>    S\d4f4f4f4f4f4f4$6h94u""""4  4$$$"|  d4$"d4$$r/T0  %00b#01t50E5&0z9#L9090PcH$ Q!ccc446$dcccE5""""00 UCL HUMAN RESOURCES DIVISION OCCUAPTIONAL HEALTH SERVICE ON-OFFER REFERRAL FORM STRICTLY CONFIDENTIAL Referral for Occupational Health advice following an offer of employment. To be completed in consultation with your HR Consultancy contact and submitted signed to: Occupational Health Service, Gower Street, London. WC1E 6BT via email to  HYPERLINK "mailto:ohsadmin@ucl.ac.uk" ohsadmin@ucl.ac.uk or via fax to (020) 7209 0256. 1. Applicants Details Surname: FORMTEXT       Title  FORMDROPDOWN  First name: FORMTEXT      Job title: Department & address:  FORMTEXT        FORMTEXT       Home address: FORMTEXT       Date of Birth: FORMTEXT      Gender: Male  FORMCHECKBOX  Female  FORMCHECKBOX  Telephone numbers: Home:  FORMTEXT       Mobile: FORMTEXT      Email address: FORMTEXT      Are there any particular requirements in relation to access, mobility or communication? If yes please give details:  FORMTEXT      If the employee is unable to attend OH please discuss the case with your HR consultant and enclose the applicants signed consent form to allow us to contact their treating clinician under Access to Medical Reports Act 1988.  FORMCHECKBOX  tick here if enclosed.Please provide a brief overview of the job description of the employee including tasks, hours, overtime and sites worked at.  FORMTEXT       2. Details of Manager and HR Consultant requesting assessmentManager s name: FORMTEXT      Address: FORMTEXT       Job title: FORMTEXT      Contact number; FORMTEXT      Department; FORMTEXT      Email: FORMTEXT      HR Consultant s name: FORMTEXT        HYPERLINK "http://www.ucl.ac.uk/hr/staff/hr_staff_contacts.php" http://www.ucl.ac.uk/hr/staff/hr_staff_contacts.php (click on this link to find your HR contact)3. Reason for referral. Please outline the main issue(s) initiating this request, including the effects of the health problem on work performance and attendance as stated by applicant or previous employer.  FORMTEXT       4. 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FORMCHECKBOX Is there an underlying medical condition impacting on the individual s ability to carry out the duties outlined in the job description? FORMCHECKBOX Are any adjustments to the work tasks or environment recommended?  FORMCHECKBOX Is there further requirement for medical support or intervention? FORMCHECKBOX Is the health problem likely to recur or affect future attendance? FORMCHECKBOX In your opinion, does the health problem meet the criteria for disability as defined within the Equality Act 2010?If other specific advice in addition to the above is required please state here:  FORMTEXT        6. Referral authorisation (the referring manager named above must sign here) Please complete the following by ticking the boxes below:  FORMCHECKBOX  I confirm that I have discussed the reasons for this referral with the applicant and departmental HR Consultant.  FORMCHECKBOX  I am aware that the applicant will receive a copy of the resulting report. PLEASE NOTE: if the applicant is unaware of your reasons for referral we may not be able to complete this assessment.If completing electronically type your name below. This indicates your agreement to the above statements (section 6) and must be emailed from your named UCL email account. Alternatively, print the form, sign and scan as a PDF file. 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