Occupational Health Referral Form

🪞 Transparent pricing model

👥 In-person and 💬 Digital services

🏛️ All prices are subject to VAT

Focused young man using a laptop while listening to music through earphones in an office setting.

Looking for our fast-track digital health services?

Our digital services allow employees to complete a self-reporting questionnaire at their own pace and in a way that suits their information processing style. This means they can take the time they need to read and understand the integrated health education and information. This means they are more likely to recognise any interaction between their health and work.

Informed consent is integrated into the assessment, delivering an instant adjustments report for their employer to consider.

🏢 Employer (Organisation) Name *

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

Employer's postal address *

⚠️ Please note that this is an IN-PERSON consultation. For digital health assessments, please click the services box at the 🔝 of this page.

Employer's website address (if applicable)

📑 This helps us to understand your business and policies where relevant.

🤵‍♂️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.

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👤 Accountable Manager’s Authorised Delegate

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

📧 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: ➤ Human Resources ➤ Health & Safety ➤ 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.

📲 Professional Advisor's DIRECT contact number *

📵 Please note that calls may be made from an unknown or withheld number.

🤵‍♂️Employee name* *

👥💬Consult with the Employee about the reason for the referral before you enter the employee's details. 👨‍👦‍👦 For GROUP assessments, enter the name of the group coordinator, responsible for arranging the assessments. 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"

📧 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 (For GROUPS, enter Coordinator’s number) *

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

Consultation preference (subject to arrangement) *

On-site (subject to travel costs)
Telephone (Calls made from withheld number)
Video conferencing (MS Teams)

⛑️ Guidance on occupational health is available here:

https://www.acas.org.uk/using-occupational-health-at-work/using-occupational-health-to-help-someone-at-work

Employer's Registered Company Number:

Help us to understand your business, industry and health and safety trends so that we can tailor our services to your needs.

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

Date of birth

This is used to identify workers who are statistically more vulnerable to health and safety exposures and incidents.

Employment start date *

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

National Insurance Number *

If the services requested is Statutory Health Surveillance, this MUST be the NI number.

Employee's occupation or role

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

Job / role activities and accountabilities (Individual OH services only)

Tell us about the job accountabilities, demands, hazards, qualifications and skills here. Do NOT paste a generic job description, as we will have to return the form to you, and this will result in set-up delays.

Work Barriers, Difficulties and Impairments

Briefly describe the difficulties your employee is having doing their job: Factors affecting your employee at work in a negative way: Disabilities, health conditions or impairments that are affected by work activities, environment or exposures

Workplace barriers, difficulties and impairments

Select required IN-PERSON 👥💬 SERVICE *

GUIDANCE Telephone consultations (🤳🏽) are delivered via: ➤ Microsoft Teams 🎦 ➤ Telephone 📲 On-site services may be subject to additional costs: 🔬 Laboratory fees 📮 Packaging and postage 🧑‍🔬 Technician services 🛣️ Travel and mileage ⚠️ If you need a FAST-TRACK DIGITAL ASSESSMENT service, click the DIGITAL services box at the 🔝 of this page.

Other Accessibility or Inclusion support (not listed above)

Additional question(s) to support decision-making

GUIDANCE FOR EMPLOYERS ♿ The Equality Act Section 20–21 documents the Employer's “duty to make reasonable adjustments”, specifically when: ➤ There is impact on "daily living activities" (including work) ➤ Duration is "long-term”, “fluctuating” or “relapsing-remitting" ➤ Condition is “degenerative” and/or , e.g. neurological disorders

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.