THE UNIVERSITY OF LIVERPOOL - Get as DOC

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					                                                     HUMAN RESOURCES DEPARTMENT

                                            Consent for Referral to Occupational Health

Name of employee......................................................................................

Department................................................................................................

Post...........................................................................................................

Date of Birth ………………………………………………...............................

Date of Commencement of Employment…………………………………………

I confirm that I understand the purpose of this referral is to obtain objective, independent medical advice to
assist with a management decision regarding my current fitness for work. In accordance with the terms and
conditions of my contract of employment, I hereby provide consent for the referral, the consultation and for a
report to be sent to Human Resources based on the consultation.

I have also been informed that a subsequent meeting may be arranged to discuss the outcome of the
consultation and that HR will provide me with a copy of the report.



Employee Signature:                   …………………………………….                                                Date………………………..



Referring Human Resources Manager:



Name: ....................................................................................


Signature: …………………………………………………..                                                        Date………………………..




Please sign and return in the pre-paid envelope provided within seven days of the date of the attached letter in
order that your appointment can be arranged with Occupational Health.

				
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posted:9/13/2012
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