Digital OH assessment referral form

Digital assessment referral form

🪞 Transparent pricing model

👥 In-person and 🧑🏻‍💻 Digital services

🏛️ All prices are subject to VAT

Digital OH assessment referral form

Organisation (Employer) Name *

Enter the organisation that should appear on the report.

Employer's address *

👷 Accountable person, responsible for managing health at work e.g. Line Manager, H&S Advisor, HR Advisor, Risk Manager *

First

Last

👷 Enter the name of the Accountable Manager, who is responsible for managing your Employee's Health, Safety and Wellbeing. 🔚 If you are not the accountable manaer, please add your name to the Additional Notes at the end of this form.

Accountable manager's email address *

Confirm Email

📥 Use an email account that can be accessed by people responsible for ensuring the Health, Safety and Wellbeing of Employees.

Employer's Company Registration No: *

Registered company number (Charities Commission, Companies House or NHS practice identifier)

Employer's website addresss

Tell us about your core business or industry sector (Complete this section if you have NOT previously registered as a client)

referral the hazards

Employee's name 🔐 ONLY enter their personal information AFTER you have consulted with them *

First

Last

Person who needs an occupational health assessment

Date of birth *

NB This is used to identify young workers, who are statistically more vulnerable to health and safety incidents, due to inexperience or immature risk-taking behaviours.

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 personal email address *

Confirm Email

Enter the email address that they will use when accessing this from home. For security we do not recommend using a work email.

Employee mobile number *

This is in case the employee needs support to access the online portal.

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 description - please only complete this if you have selected 🙋

Select the OH service you need *

🌐 Pre-placement adjustments report - basic risk - £35.00
🌐 Pre-placement adjustments report - occupation risk, e.g. healthcare, safety critical - £50.00
🌐 Health monitoring - to evaluate the effectiveness of H&S control measures - £65.00
🌐 Health surveillance - for employees exposed above regulatory action levels - £65.00
🌐 Incident and symptom report - £60.00
🌐 Individual adjustments report - £200.00
🌐 Return to work adjustments report - £200.00
🌐 Adjustments to support workplace communication and meetings - £25.00

🌐 These services are delivered via our digital platform and includes a follow-up call with our OH technician to document your consideration of 'reasonable adjustments. 🛜 Remote services are delivered via Microsoft Teams or Telephone 🛣️ On-site services are subject to mileage and travel costs.

Digital assessment referral form

🖱️Click here to make a referral for an in-person consultation

Digital OH assessment referral form