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Management Referral Form

If a colleague-in-training requires support you may need to submit a management referral form into the Lead Employer. 

If you require specific advice and recommendations for adjustments and advice on how to avoid work-related ill-health and to help sustain attendance at work, please complete the form below.

Please note, if you do not require advice in relation to the colleague's condition, please advise that the individual submits a self referral form here.

Please note, this form must only be completed by a host organisation representative.

Section 1 - Employee Details

Name

GMC Number 

Date of Birth 

Contact Number 

Home Address (Including Postcode) 

Training Region

Preferred Spoke Organisation (if training outside of NW region)

Specialty

Current Status

First Day of Absence
 

Section 2 - Referrer Details

Referrer Name

Referrer Role (Clinical Supervisor/ Educational Supervisor/Training Programme Director/Trust HR or medical staffing/PSW/Other – please specify) 

Contact Number 

Email Address

Section 3 - Reason for Referral and Background

Please provide an overview of the requirement for a referral and any additional information that may support this request 

Section 4 - Treatment and Support

Please provide an outline of the support or treatment that you or the individual may have received or is due to receive to support the referral 

Section 5 - Additional Information

Have any reasonable adjustments already been implemented? If so, what are they and are these working? If not, please advise us of further details regarding this 

Section 6  - Additional Questions 

Please advise us of any additional questions that you would like to be answered during an appointment with Health, Work and Wellbeing