Private and Confidential

Providing Occupational Health Counselling and Screening 
Services 	

Title Full Name of Employee
DOB:  DD month YYYY
Post -      
Payroll number 	Referral ID:      

Case Reference No:      	
		
	Help Desk:      	
		
	Date:       	

Primary Contact Name 
Role 

I have written this report to provide advice in response to the business referral form for Title full Name  which we received on DD Month YYYY.This advice is based on the assessment that took place on DD Month YYYY.

In the sections below I have described the relevant medical issues, assessed his current capacity for employment, commented on the outlook as well as addressing any specific questions you have raised.

Description of Relevant Medical Issues 
Title Surname.

Current Capacity for Employment
Title Surname

Outlook
Title Surname

Response to Specific Questions
Title Surname

I hope you find this report helpful and leave it to you as the manager to decide if any recommendations made are feasible for the business to support. 
I have discussed the general contents of this report with the employee and they are aware I am sending it to you; it is recommended you discuss the report with the employee, providing a copy if requested. If you have any queries about the contents of this report I would be more than happy to discuss. 

Ms XX

Occupational Health Adviser