Standard Referral form

STANDARD REFERRAL FORM
Thank you for submitting your referral to Collingwood Health.

Please note that all referrals will go through our triage process to ensure we arrange an appropriate appointment to provide the most effective outcome. Once triaged, you will receive an email confirming the type of triage and costs. If you have questions prior to making your referral, please contact our team: 0114 399 3453 or 01753781601.
Purchase Order *NEW*
*NEW* - If your company is fully PO compliant, please enter the PO number here: (required)*
You MUST complete this section. If you do not have or use a PO please insert your name or N/A.
*NEW* - By submitting this referral you are authorising us to go ahead and book the appointment (required)*

YesNo
Would you like us to: (required)

Contact the EmployeeBook through the Referring ManagerBook through the HR Representative
The preferred means of contact is: (required)*

TelephoneEmailPost/Appointment Letter
Employee Personal Information
Title
Full Name (required)*

First NameLast Name
Date of Birth (required)*

DayMonthYear
Address (required)*
Primary Contact Number (required)*

Area CodePhone Number
Secondary Contact Number

Area CodePhone Number
E-mail (Personal)
PLEASE INCLUDE IF POSSIBLE
Employee Id Number*
E-mail (Work)
Preferred Contact method or any special instructions
Employee Role Information
Company Name (required)*
REQUIRED FOR ALL SUBMISSIONS
Referrer Name (required)*
REQUIRED FOR ALL SUBMISSIONS
Referrer Business Address (required)*
REQUIRED FOR ALL SUBMISSIONS - Report will be sent to this address
Employee Workplace Address
REQUIRED FOR ONSITE APPOINTMENTS (e.g., Workplace Assessments, DSE)
Line Manager Name
Employee Time with Company
Employee Time in Current Role
Employee Job Title
Department Name*
Employee Job Description ( please upload)

Upload a File

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Job Role (please select from below)
Job Detail - Managers (please select from below)
Job Detail - Professional (please select from below)
Job Detail - Technicians and associate professionals (please select from below)
Job Detail - Clerical support workers (please select from below)
Job Detail - Sales and support workers (please select from below)
Job Detail - Skilled agricultural, forestry and fishery workers (please select from below)
Job Detail - Craft and related trade workers (please select from below)
Job Detail - Plant and machine operators and assemblers (please select from below)
Job Detail - Elementary occupations (please select from below)
Job Detail - Armed Forces occuaptions (please select from below)
Other - Please describe
Role Requirements (please tick all that apply)

Full TimePart TimeShift WorkHome WorkerLone WorkerNight WorkerOther
Please give a brief description of the job
UPLOAD A JOB DESCRIPTION AS WELL
Job Description

Upload a File

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Referral Reason
Please select referral type (required)*

Long Term AbsenceFrequent Short Term AbsenceIll Health Retirement / Medical CapabilityFitness for WorkOccupational Exposure / Hazard ConcernsPre-Natal AssessmentAdvice and Recommendation on current Medical Situation
Please give details of the reason for referral (required)*
Has the employee previously been referred to Occupational Health (required)*

YesNo
If yes please provide date of referral

MonthDayYear
Date
Please give details of previous referrals
Absence History
Current absence start date

DayMonthYear
Date
Reason for this absence
Number of spells of absence in the last 12 months
Working days lost in the last 12 months
Please upload any absence history

Upload a File

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Please describe reasons for previous absence
Please describe any action you have taken to support the employee's wellbeing
Do you have any scope to make adjustments to the employee's role, if so, please describe
Are you able to accomodate phased return to work, if so, please describe parameters
Please note that the ultimate decision regarding whether an impairment meets the disability provisions of the Equality Act 2010 lies with an employment tribunal or court. Do you want an opinion from the clinician as to whether the Equality Act 2010 is likely to apply ?*

YesNo
The report will cover a summary of the relevant medical problems, fitness for work, any limitations for employment, any recommended adjustments or restrictions, likely date of return to work if known, likelihood of future sickness absence and any particular work related factors impacting on their health. Would you like to add any additional questions?*

YesNo
Question 1
Question 2
Question 3
Please provide any additional information that may be relevant to this referral
Please upload any further supporting documents (eg Previous GP / OH Reports)

Upload a File

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Referring Person Information
Please tick to confirm (required)*

I can confirm that the reason for the referral has been explained to the employee. I understand that the Data Protection Act allows the employee to see a copy of this referral if requested.
Referrer's Full Name (required)*
Referrer's Job Title (required)*
Phone Number (required)*

Area CodePhone Number
E-mail (required)*
Copy Required ?

Please send a copy of the referral to the email address above
Second Referrer's email where applicable
Please describe any important time factors or events we should be aware of (eg. Holidays / Appointments)
Date

DayMonthYear
Collingwood Health GDPR Privacy Notice:

collingwoodhealth.com/privacy-notice/
Should be Empty:

STANDARD REFERRAL FORM

Purchase Order *NEW*

Employee Personal Information

Employee Role Information

Referral Reason

Absence History

Referring Person Information

Purchase Order NEW