Submit a Referral Employee Details Submitting this referral is confirming agreement of our terms and conditions.Referral Date DD slash MM slash YYYY Type of ReferralManagement Referral OH Advisor / Allied Healthcare Professional (£125)Management Referral OH Physician (£290)Physio Package (up to 5 sessions & report) (£200)Counselling Package (up to 7 sessions & report) (£450)Personal DetailsEmployee Name First Last Birth Date MM slash DD slash YYYY Contact DetailsHome Address Street Address City Postal Code Mobile phone numberEmail Address Injury/IllnessCurrent injuries/illnesses Date of injury/illness DD slash MM slash YYYY Work DetailsPlease provide details about workJob Title Job DescriptionEmployee's Duties or Job DemandsWork Address Street Address City Postal Code Reasons for the ReferralPlease provide the reason for this referralReasons Fitness for work concerns Persistent short-term absence Long term absence Return to work following absence Other Choose all that applyAdditional InformationHow long has the employee been off sick in the last 6 months? Has the employee failed a return to work despite previous OH intervention? Please provide any other information relevant to the referralSpecial InstructionsFor example, dates/times that we should avoid, best times to contact the staff member etc.QuestionsIf you are making a Management Referral, please select the questions you require answering: (Any other referral type - click 'Next Step')Questions In your opinion, is the employee fit to continue working in their current role? Please provide details of what (if any) aspects of the role the employee is not fit to continue with or which duties require adjustments. Is the employee likely to be able to provide regular and effective service in the future? In your view, is the employee likely to be covered under the disability provision of the Equality Act 2010? In your opinion, given the medical history, how effective is current treatment likely to be? Is the employee’s illness caused or exacerbated by their work? If the employee is taking medication, is it likely to impair their ability to do their job safely and effectively? Do you have any special recommendations regarding the hours that the employee may be able to work and the frequency of their attendance at work, for example, if a phased return is recommended, please confirm on what basis? Is the employee fit to participate in a meeting to discuss their capability to continue in their current role? If not, are there any adjustments which would enable the employee to participate in a discussion about their capability with us? Is there any other relevant information or advice you feel will help us to deal with the current situation by managing the employee’s on-going employment and assisting in getting them back to work/helping them to stay in work? Additional Questions (max 2)Referrer DetailsPlease provide your personal detailsPersonal DetailsReferrer Name First Last Referrer Phone NumberReferrer Email Company DetailsCompany Name Referrer Position Finance Contact Person Name Finance Contact TelFinance Contact Email LegalEmployee consent confirmation(Required)Please confirm that you have discussed the contents of the referral with the employee and they have consented to be contacted by Innovate on that basis. It is important that the full reason for the referral is explained to the employee prior to submission. Innovate Healthcare are unable to proceed without confirmation that you have completed these steps. I confirm