Digital OH assessment referral form

🏢 Employer (Organisation) Name *

Include your employee’s division or section, if different.

Employer's postal address *

⚠️Please note that this is an ONLINE assessment. For in-person and on-site services, please click the services box at the 🔝 of this page.

🤵‍♂️Accountable Manager *

The Accountable Person is the person responsible for considering the recommendations and managing your Employee's Health, Safety and Wellbeing. If you are NOT the accountable manager, but are completing this form, add your name to the ‘Accountable Manager’s Authorised Delegate' section below.

👤 Accountable Manager’s Authorised Delegate *

❗ Complete this section if you are submitting this form but are NOT the Accountable manager, e.g. Professional Advisor or Executive Assistant.

📧 Accountable Manager (or Authorised Delegate) email address *

Confirm Email

✅ Provide an e-mail address that can be accessed by the ACCOUNTABLE person and/or their AUTHORISED delegate. 🚮 Remember to check your ‘junk / spam email boxes’ if you do not see a confirmation email from us. 📮 We strongly recommend that you send a test email to enquiries@workabilitysolutions.co.uk to add us to your ‘safe senders’ list. ⚠️ Please note that we are not able to respond to ‘out of office’ responses.

📞 Accountable manager's DIRECT contact number *

📲 Provide a DIRECT contact number for the Accountable Manager or their Authorised Delegate for confidential correspondence.

💼 Professional Advisor (If not applicable, enter N/A in both fields) *

First

Last

⚠️ You MUST enter the Advisor’s name if you wish the report to be shared and/or discussed with them: ➤ Health & Safety ➤ Human Resources ➤ Risk

📧 Professional Advisor's contact e-mail

Confirm Email

Use an email account that can be accessed by the Advisor’s delegates. Please note that we are not able to respond to ‘out of office’ responses.

🙋‍♂️ Digital Accessibility and Inclusion needs (select ALL that apply)

Access to a keyboard
Literacy (reading or writing) skills
Access to the internet
Motivational support to overcome these barriers
Confidence to use an online service
Trust in online services or the internet
Digital skills
No Digital Accessibility Needs identified

GUIDANCE NOTES The Employer retains responsibility for identifying and implementing reasonable adjustments in accordance with the Equality Act 2010, including any requirement for support mechanisms such as a support worker, interpreter, or other auxiliary aid during and following Digital Occupational Health Assessments. To enable equitable access to the Occupational Health assessment process, accessibility needs relating to the assessment itself should be identified IN ADVANCE where possible. The Occupational Health Provider will take reasonable steps to facilitate accessible engagement for the assessment, including consideration of communication needs, and will provide independent clinical advice to inform this process. The Occupational Health Provider will also provide independent clinical advice on functional impact and recommendations for workplace adjustments, and will cooperate with the Employer in supporting accessible engagement. Employers are responsible for ensuring that all agreed adjustments, including accessible communication arrangements, are effectively implemented and maintained. Further best practice guidance is available via the Health and Safety Executive:

https://www.hse.gov.uk/disability/best-practice/accessible-communication.htm

Other Accessibility or Inclusion support (not listed above)

Employer's Company Registration Number

Registered company number Charities Commission Companies House NHS practice identifier

Employer's website addresss (enter N/A if you do not have one) *

📈 This is important for additional services, such as reporting on workplace health risks and symptom trends.

What is your company’s main business or industry sector?

Employee or Applicant who will be completing the online self-assessment questionnaire. *

First

Last

👥💬 Consult with the Employee about the reason for the referral before you enter the employee's details. GUIDANCE: Employers can ask a worker if they will agree to an occupational health assessment to: 1. Get any support they need to feel better and be able to do their job 2. Return to work safely and more quickly 3. Avoid their employer making big decisions without important information 4. Avoid anything that could cause further health or absence issues ✍️ The Employee will be asked to give express permission before the recommendations report can be shared with their employer. See GDPR section (below) for details of "NO CONSENT"

Date of birth *

Age is used to identify workers, who are statistically more vulnerable to health and safety incidents, due to vulnerability, e.g. health, inexperience, understanding.

Employment start date *

NB This is used to identify new starters who are more vulnerable to health and safety incidents in their first 6 months of employment.

National Insurance Number *

If your employee is likely to be working above occupational exposure limits, requiring Statutory Health Surveillance, this MUST be the NI number.

Employee's contact e-mail *

Confirm Email

💌 We recommend you provide the Employee's PERSONAL email address to ensure data privacy when corresponding about employment health issues. Employees are responsible for checking their emails (including spam folders) once they have been consulted about this referral. Please note that we are not able to respond to ‘out of office’ responses.

📞 Employee’s contact number *

📲 This phone MUST accept calls from unknown and/or withheld numbers

Employee's occupation or role *

Occupational groups are listed alphabetically. If you are not sure which applies, describe the occupation in the free text box below.

Essential information for ‘Read and Transcribe’ service

✋ We will NOT contact your employee UNLESS you have requested the 'Read and Transcribe' service.

📲 Employees should be informed in advance that they will receive a call from an unfamiliar or ‘withheld’ number.

📵 The employee must ensure that calls are not barred from ‘withheld’ numbers and answer the phone.

e-mail Professional Service

GDPR Data Processing Agreement *

I have read and understood the GDPR Data submission and processing agreement (below).
I am authorised to request occupational health services on behalf of the “Employer”.

GDPR DATA SUBMISSION AND PROCESSING AGREEMENT
1. PURPOSE OF SUBMISSION
By submitting this form, you (the “Employer” or “Authorised Representative”) confirm that you are requesting occupational health advice in relation to an employee and/or worker for the purposes of:
➤ Assessing fitness for work
➤ Assessing and managing risks associated with the relationship between health, impairments of daily living, work activities and environment(s)
➤ Considering and identifying “reasonable adjustments"
➤ Facilitating attendance or performance management or return to work
➤ Supporting health, safety and wellbeing management
2. ROLES AND RESPONSIBILITIES
➤ The Employer acts as a Data Controller for the personal data submitted.
➤ The Occupational Health Provider acts as an independent Data Controller in respect of its own processing activities and determines the purposes and means of processing independently for clinical assessment and advice.
Each party acts as a separate and independent Data Controller and is responsible for its own compliance obligations.
Each party will comply with:
➤ Applicable common law duties of confidentiality
➤ UK GDPR
➤ Data Protection Act 2018
➤ Applicable occupational health professional and ethical standards
3. LAWFUL BASIS FOR PROCESSING
The Employer confirms that:
➤ A lawful basis exists for processing and sharing personal data, including (where applicable):
➢ Article 6 UK GDPR (e.g. legitimate interests, legal obligation, or contract), and
➢ Article 9 UK GDPR condition for processing special category data
➤ The processing is necessary, proportionate, and limited to what is required to achieve the stated purpose
4. EMPLOYEE AWARENESS AND TRANSPARENCY
The Employer confirms and warrants that:
➤ The employee/worker has been informed in advance of the occupational health referral
➤ The purpose, nature, and intended outputs of the referral have been clearly explained, including that an occupational health report may be produced and shared
➤ The employee/worker has been provided with, or signposted to, a Privacy Notice explaining how their personal data will be used
5. CONSENT AND DATA SHARING PRINCIPLES
The Employer acknowledges and agrees that:
➤ The Occupational Health Provider will seek explicit, informed consent directly from the employee before any health information is disclosed to the Employer;
➤ No medical information will be shared without employee consent unless required by law, including where there is a serious and imminent risk to health or safety;
➤ Any information shared will follow the “minimum necessary” principle, typically limited to:
➢ Functional capacity
➢ Fitness for work
➢ Recommended adjustments
➤ Clinical diagnoses will not normally be disclosed to the Employer.
6. NATURE OF DATA SUBMITTED
The Employer agrees:
➤ To submit only data that is relevant, adequate, and limited to what is necessary for the referral
➤ Not to include excessive, irrelevant, or highly sensitive data unless strictly required
➤ That submitted information may include personal and (potentially) special category data
7. SECURITY AND HANDLING OF DATA

The Employer confirms that:

➤ Personal data submitted has been obtained and is shared securely, lawfully, and in accordance with its internal data protection policies
➤ Internal organisational controls are in place to protect personal data
➤ Access to occupational health reports within their organisation will be restricted to authorised personnel on a need-to-know basis
8. DATA RETENTION AND FURTHER SHARING
The Employer agrees that:
➤ Occupational health reports provided will be treated as confidential, sensitive data;
➤ Further sharing within the organisation will be:
➢ On a strict “need to know” basis by authorised individuals responsible for managing the employee’s health, safety, or employment needs and responsibilities, and
➢ Only where necessary for employment, health and safety, legal or safeguarding purposes.
➤ The Employer will ensure that occupational health information is not used for purposes unrelated to employee health, safety, or wellbeing without an appropriate lawful basis;
➤ The Employer will retain occupational health reports only for as long as necessary and in accordance with its retention policies and legal obligations;
➤ Any further disclosure to third parties will require:
➢ An appropriate lawful basis, and where applicable, further employee consent.
9. EMPLOYEE RIGHTS
The Employer acknowledges that employees retain their rights under UK GDPR, including:
➤ Right of access
➤ Right to rectification
➤ Right to restrict or object to processing
➤ Rights relating to automated decision-making (where applicable).
10. NO CONSENT / WITHDRAWAL OF CONSENT
The Employer understands that:
➤ If the employee does not consent to the release of occupational health advice:
➢ The Employer may receive a notification of “no consent” only;
➢ No health information will be disclosed
➤ Consent may be withdrawn by the employee at any time prior to disclosure.
11. CONTACT AND QUERIES
For data protection queries, requests, or concerns, the Employer should contact their internal Data Protection Officer and/or the Occupational Health Provider’s Data Protection Lead.

GDPR Confirmation *

I confirm that all the above statements are true.

Before you start, do you need in-person or on-site services?