Ergability

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Referral Form - face to face assessment

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Face to face assessment - occupational health management referral

Please complete the following information to refer a employee for a face to face assessment

We will contact you to confirm assessment details once we have received the completed referral form.

Please contact Ergability at info@ergability.com or call 03333 554 184 if you require any additional information.

Referring employer name *

First Name

Last Name

Referring employer contact number *

Referring employer email address *

Name of organisation *

Consent - Has the employee consented to the referral and issue of consent form? *

N.B. Ergability will issue consent form directly to referred individual upon receipt of completed online referral form.

Yes

Employee's name *

First Name

Last Name

Employee's date of birth *

Employee's contact email address

Employee's job title *

Employee's contact phone number *

Nature of employee's reported health condition/s *

How long has the employee experienced the health condition/s

Goals for assessment (information required) *

Fitness for work recommendation

Additional information on nature of health condition/s and prognosis

Recommended workplace adjustments and / or return to work plan

Recommendations to address any identified occupational health related issues / barriers

Employee's current work status *

At work on full duties / hours

At work on modified duties and / or hours

Off work

Does the employee have a current fit note? *

Yes

Please add details of any current fit note including date of expiry and any recommendations

Employee's job title *

Employee's working hours per work *

Does the employee regularly work night shift (working between 10pm and 4am)? *

Yes

Details of job demands *

Please check the relevant boxed below for specific demands that are required as part of the employee's job role

Lifting - floor to waist

Lifting - waist to shoulder

Lifting - above shoulder

Carrying

Pushing / pulling with significant force

Sitting

Standing

Walking

Stair climbing

Ladder climbing

Driving (including car, fork lift, lorry etc)

Working at heights

Working in confined spaces

Kneeling, squatting and / or spinal bending

Working in hot / cold conditions

Working with vibrating tools and / or machinery

Working to fixed time constraints

High workload demands

Critical thinking and problem solving

Managing people

Please add details of any other relevant job demands

Please advise if your company provides any of the following health and / or wellbeing services

Employee Assistance Programme (EAP)

Physiotherapy

Counselling and / or psychological support

Please add details (including contact number) of any health and wellbeing services

Please provide any additional referral information

Thank you!

Email: info@ergability.com Phone: +44 (0)333 355 4184 Business Address: Bradbury House, Mission Court, Newport, NP20 2DW

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