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Workplace adjustments referral form

Workplace referral form

Type of assessment required

Face-to-face
Online

Employee details

Employee information

Title:
First name:
Last name:
Job title:
College/institution name:
Employee contact information (these will be used to contact you to arrange the assessment)

Office telephone number:
Mobile telephone number:
Email (work):
Employee work address

Building number/name:
Street:
Town:
County:
Postcode:
Employee working hours and contact times

Days worked:
Hours worked:
Shift patterns:
Dates not available for an assessment:
Preferred contact day / time:

Line manager’s details

Line manager’s information

Title:
First name:
Last name:
Office telephone number:
Mobile telephone number:
Email:
Please note a copy of the final report will be sent to your line manager

Workplace environment information

This section should provide general information regarding the employee’s work role, tasks, current workstation set up and any specific workplace adjustments already put in place to support the employee at work.

Details of workstation environment (select one of the following options below):

Hot desking
Works from home
Works from a variety of geographical locations
Designated workstation
Works from vehicle
Customer facing workstation

Current workstation setup (select all that apply):

Desktop computer
Standard mouse and / or keyboard
Assistive software
Laptop
Specialist mouse and / or keyboard
Specialist chair

Please describe any workplace adjustments already in place supporting the employee’s current difficulties. e.g. physical adjustments (IT equipment, software, specialist furniture) and soft adjustments (additional breaks, reduction in targets, changes to role):

What does the employee’s job role involve? (select all that apply):

Computer data input using Office and internal applications
Hand-written note taking
Manual lifting / carrying
Customer face-to-face interaction
Telephone work
Attends meetings
Expected to travel within job role

What type of condition relates to this referral (select all that apply):

Physical: e.g. mobility or dexterity condition
Audio: e.g. hearing
Neurodivergent e.g. AS, SpLD, Dyslexia
Mental health
Visual
Other

* If you ticked ‘Hearing’ please advise whether the employee wears a hearing aid?:

Yes
No

Supplier (e.g. Specsavers, Boots, ):
Brand (e.g. Advance, Sivantos, Widex, Phonak):
Model (e.g. 3Nx, BD50, Unique 220, primax 1px):
Style (e.g. behind the ear, in the ear, in the canal):
Is a Loop Programme available on the hearing aid? (sometimes known as a “T” Setting):
Is a Loop Programme enabled on the hearing aid? (this may need to be done by the audiologist):

Reason for referral

Please describe in as much detail as possible the condition affecting the employee which the employee requires workplace adjustment support and any information on how the condition impacts on the employees job role (e.g. Dyslexia, lower back condition, RSI in right hand) :

Please let us know if you have any specific request or questions regarding the assessment :

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Contact info

[email protected]

01204 534 311

Barry Bennett Ltd
Bennett House, Viking Street
Bolton BL3 2RR