OCCUPATIONAL HEALTH

STUDENT REFERRAL FORM

FOR OCCUPATIONAL HEALTH ASSESSMENT AND ADVICE ON FITNESS FOR PLACEMENT

________________________________________________________________________________

PRIVATE AND CONFIDENTIAL

Once completed by the Tutor/Program Lead responsible for the student, please email to studentoh@essex.ac.uk and wellbeing@essex.ac.uk. Please ensure the student is aware of the referral before submitting.

We will be unable to process the referral if the form is not completed in full.

Student Details (Please complete all sections)
Title:	Pronouns:	Full name:
Department/School:	Date of birth:
Programme title:	Date Programme commenced:
Which campus is the student based at?	Colchester	Southend
Please state the student’s preferred contact method: Essex Email Personal email Telephone
Personal email address:	Mobile telephone number (this will also be the number used for telephone appointments if applicable): Consent for text reminder: Yes No
Home address:
GP Surgery Address:
If registered at the University Health Centre, does the student give consent for their OH report to be sent to their GP?	Yes	No	N/A
Referrer’s details (Please complete all sections)
Name:	Contact telephone No:
Position:	Essex E-mail:
Student Support Link: Please ensure the referral is shared with the relevant Student Support Links listed opposite and indicate which person has been notified by ticking the relevant box.	Laura Spinks - Accessibility and Wellbeing Manager (Mental Health) (For referrals relating to mental health)
NB. Occupational Health will obtain consent from the student to send the Occupational Health Report to the relevant student support links	Paula Lightfoot – Senior Accessibility & Wellbeing Manager (For referrals relating to other medical conditions)
All referrals must be shared with the DDLO (Department Disability Liaison Officer)
Current status (Please complete all sections)
Is the student currently attending university or placement? University: Yes No Placement: Yes No	If not attending, please state the date that the absence commenced or date they are due to start placement:
Normal university or placement hours/pattern:
Reason for referral (Please tick most relevant option)
Frequent short term sickness absence from placement	Fitness to return to placement after illness or injury
Fitness to attend classes/placement	Long term sickness absence
Accident at University/Placement	High-risk pregnancy
Other (Please state):
Reason for referral (Please complete) Include relevant background information such as recent changes/adjustments, placement area issues, performance concerns, existing disabilities or any support offered to date by the University.
What are the specific questions you would like OH to answer to help manage/advise/support the student? (Please complete this section) Such as: Is there an underlying health problem that affects the student’s attendance/performance on placement? Is the student medically fit for the placement? If not, when are they likely to be medically fit for the placement? When is the student likely to be fit to return to placement? Is the student likely to be able to maintain a regular and effective attendance on placement? What reasonable adjustments are required to be considered to enable the student to attend/be supported in their placement? Please number your questions.
Please provide any additional relevant information (such as coursework marks, late submission/extenuating circumstances applications, student case worker involvement which may be relevant to the referral)
If the student is on placement, please provide a brief overview of the student’s work duties and placement objectives.
Student placement requirements (please tick)
Using display screen equipment / VDU Work	Working with chemicals/biological substances
Shift work/Night work	Manual handling
Working under pressure, exposed to violence/responding to emergency situations	Working in noisy environment

Referring lecturer/personal tutor information
Please note: The referral will be shared with the student and used as the basis of their consultation in Occupational Health. Occupational Health will need to obtain consent from the student to send the Occupational Health Report based on the consultation. If the student withholds their consent, you must proceed without the benefit of Occupational Health advice. It is the referring lecturer/personal tutor’s responsibility to provide the Student Support Link and the student with a copy of this referral. Please ensure the student is aware that the OH report will also be copied to Student Wellbeing and the Department Disability Liaison Officer (DDLO) It is the referring lecturer/personal tutor’s responsibility to update Occupational Health on any changes that may affect the student’s referral, prior to their assessment. Please ensure the student is advised that all correspondence regarding their assessment will be via their university email address.
I confirm that I have read the above information and have spoken to the student providing them and the Student Support Link with a copy of this referral. Name: Signature: Date:
Please Note: If you are referring a student for psychological support or counselling only, this does not need to come through OH and you can refer via the Student Wellbeing Team. If you have any immediate concerns about a student, please complete the Student Welfare concern form and send through to SWIS. Report a concern about a member of the University community | University of Essex Following receipt of the Occupational Health report you will need to make an appointment to speak with the student about the outcome and to discuss any recommendations or adjustments. Occupational Health may suggest a case conference takes place. For further advice on making the recommended adjustment(s) you may wish to speak to the relevant Accessibility Manager or your department’s Placements team.