Occupational Health Referral form For Employers
Date of Referral: 19/05/2012
SNA Details:
Name & Address:
Date of Birth:
PPSN:
Contact Number:
Job Title:
Length of Service in Yrs.:
Details for person in the school managing case who can be contacted to discuss case if required:
Full Name:
Job Title:
Phone Number:      Mobile Number:
Email:
School Name & Address:
School Roll Number:
Attendance Record - (please specify 'n/a' for fields not applicable to you)
Please give details of absences owing
to illness in the past 12 months:
In Work at Present?
Duration of Current Absence if Applicable:
Certified Reason for Absence:

Reason for Referral & Background Workplace Information

Reason for referral and issues to be addressed

(please choose category)
Non Discretionary Sick Leave Absences(Please specify)
Discretionary Sick Leave Absences (Please specify)
Other (please specify)
Details of the nature of the specific duties of the post and any associated duties:
Any change in the Individual’s performance and their duties prior to commencement of sickness absence:
Any reason that the employing organisation may have to believe that the absence may be work related:
Any alcohol or drug related problems:
Any other information considered relevant to the referral:
Name and address of where the confidential report is to be sent:

Confirmation that the reason for referral has been fully explained to the SNA:
 Yes    No
If NO please state reason:
Referral Form Completed By:
Job Title: