Workplace adjustments referral form

Workplace referral form

Type of assessment required


Employee details

Employee information

Employee contact information (these will be used to contact you to arrange the assessment)

Employee work address

Employee working hours and contact times

Line manager’s details

Line manager’s information

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):

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

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

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


Reason for referral

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