AseptA Occupational Health Referral

Employee Name
Date of Birth
Address
Email
Contact Number
Job Title
Department
Current work status
Date of first absence day (yyyy-mm-dd)

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1) Is the employee fit for work, please state the reasons why fit/not fit?
2) Is the employee receiving the appropriate care and treatment?
3) Is a return-to-work dependent on any factors?
4) Any actions that the employer can take to facilitate an earlier return to work, and later, to prevent further absence?
5) What is the likely impact on their performance or attendance at work from this condition?
6) Are you able to estimate when a return to work is likely to occur?
7) In your opinion is the employee likely to be covered under the Equality Act 2010. Please give reasons.
8) Is the employee able to attend meetings with management, including disciplinary proceedings?

1. Please provide the following information: