Management Referral Form for RGU Healthcare Students

If the referring person could please answer each of the following questions. All fields marked * are required fields and must be completed. On submission a PDF summary of the completed referral form shall be emailed to GO Health Services, a copy sent to the referring person and to the person being referred.

The information provided will be retained by GO Health Services and will be held on a secure database and will not be used for any other purpose without your consent. Please note however some information may be shared for statistical purposes only which will not identify individuals.

For further information please visit https://gohealthservices.scot.nhs.uk/rgu/referral.

This form is also available in other formats and languages, upon request. Please Please call NHS Grampian Corporate Communications on (01224) 551116 or (01224) 552245 for further information.

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SECTION 1: PERSON BEING REFERRED

Title * DrMissMrMrsMsProf

Forename *

Surname *

Previous Surname (if applicable)

Date of Birth *

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Gender * MaleFemaleOther

Email Address *

Email

Confirm Email

Home Phone Number

Mobile Phone Number (please add if you have one)

Address for Correspondence *

Postcode *

Country of Birth * United KingdomAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua & DepsArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia HerzegovinaBotswanaBrazilBruneiBulgariaBurkinaBurundiCambodiaCameroonCanadaCape VerdeCentral African RepChadChileChinaColombiaComorosCongoCongo {Democratic Rep}Costa RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIreland {Republic}IsraelItalyIvory CoastJamaicaJapanJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmar, {Burma}NamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussian FederationRwandaSt Kitts & NevisSt LuciaSaint Vincent & the GrenadinesSamoaSan MarinoSao Tome & PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

GP Practice * Not Known / Not Registered with GPOTHER – Please SpecifyAberchirder Medical PracticeAberlour Health CentreAboyne Health CentreAden Health CentreAlbyn Medical PracticeAlford Medical PracticeAn Caorann Medical PracticeArdach Health CentreAuchenblae Medical CentreBallater ClinicBanchory Group PracticeBanff & Gamrie Medical PracticeBraemar Health ClinicBrechin Health CentreBucksburn Medical PracticeBydand Medical GroupCalsayseat Medical GroupCamphill Medical PracticeCentral Buchan Medical PracticeCove Bay Health CentreCrimmond Medical CentreCruden Bay SurgeryCruden Medical GroupCullen Medical CentreCults Medical GroupCuminestownDanestone Medical PracticeDenburn Medical CentreElgin Community SurgeryEllon Group PracticeElmbank Group PracticeFinlayson Street SurgeryFochabers Medical PracticeForres Health CentreFyvie Old Meldrum Medical GroupGarthdee Medical PracticeGilbert Road Medical GroupGlenlivet Medical PracticeGreat Western Medical PracticeHaddo Medical GroupHamilton Medical GroupHolburn Medical GroupInsch Medical PracticeInverbervie Medical GroupInverurie Medical GroupJesmond SurgeryKeith Medical GroupKemnay Medical GroupKincorth Medical PracticeKingswell Medical PracticeKintore Medical CentreLaurencekirk Medical GroupLinks Medical Practice, AberdeenLinkwood MedicalMacduff Medical PracticeMaryhill Health CentreMaud SurgeryMintlaw Group PracticeMoray Coast Medical PracticeNew Deer Medical PracticeNew Dyce Medical PracticeNewburn Health CentreNorthfield & Mastrick Medical PracticeOld Aberdeen Medical PracticeOld Machar Medical PracticePeterculter Medical PracticePeterhead Medical CentrePortlethen Medical CentreRhynie SurgeryRinnes Medical GroupRothes Medical CentreRubislaw Place Medical GroupSaltoun SurgeryScotstown Medical GroupSeafield Medical CentreSkene Medical GroupStonehaven Medical GroupStrathdon Medical CentreStrichen SurgeryTarland SurgeryTomintoul Medical CentreTorphins Medical PracticeTorry Medical PracticeTorry Neighbourhood CentreTurriff Medical PracticeVaris Medical PracticeVictoria Street Medical GroupWestburn Medical GroupWhinhill Medical PracticeWoodside Medical Group, Aberdeen

Other GP Practice

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Intake * Return to Practice2024 (September)2024 (January)2023 (September)2023 (January)2022 (September)2022 (January)2021 (September)2021 (January)2020 (September)2020 (January)2019 (September)2019 (January)2018 (September)2018 (January)2017 (September)2017 (January)

School * School of Health SciencesSchool of Nursing, Midwifery and Paramedic PracticeSchool of Pharmacy and Life Sciences

Course * B MidwiferyBSc Nursing – AdultBSc Nursing – Children and Young PeopleBSc Nursing – Mental HealthBSc Paramedic PracticeBSc Nursing (Hons)BSc Nursing (Hons) – Dual Reg. Adult and Children and Young PeopleBSc Nursing (Hons) – Dual Reg. Adult and Mental HealthBSc Nursing (Hons) – Dual Reg. Children and Young People and Mental HealthBSc (Hons) – Applied Biomedical ScienceBSc (Hons) – Diagnostic RadiographyBSc (Hons) – Nutrition and DieteticsBSc (Hons) – Occupational TherapyBSc (Hons) – PhysiotherapyMaster of PharmacyMDiet DieteticsMDRad Diagnostic RadiographyMOccTh Occupational TherapyMPhys PhysiotherapyMSc MidwiferyMSc Physiotherapy (pre-reg)Return to Practice

Date Course Commenced *

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Study / Placement Base *

Hours of Study * Full-TimePart-TimeOther

Please state the number of hours of study per week *

If on placement a summary of normal working pattern (e.g. predominately night duty, 12 hour shifts)

Summary of Duties / Description of Course *

Student Sickness Absence History (over previous 12 months – current absence first, if applicable, then in order of most recent to oldest):

Current Absence Start and Finish Dates

Reason for Current Absence

Number of Hours Lost during Current Absence

Absence 2 Start and Finish Dates

Reason for Absence 2

Number of Hours Lost during Absence 2

Absence 3 Start and Finish Dates

Reason for Absence 3

Number of Hours Lost during Absence 3

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SECTION 2: REFERRAL DETAILS

Reason for Referral (please select all that are relevant) *

• Recurrent short spells of absence
• Prolonged sickness absence
• Return to University studies (following a suspension) assessment
• Return to clinical placement assessment
• Concern about health in relation to undertaking the role
• Student has declared a health issue that may impact on ability to carry out their role
• Concern that student may have an infectious or contagious disease (in first instance email GO Health Services as soon as possible)
• Suspected substance misuse
• Other – please specify

Please give details below of the other reason for referral *

Management Information / Referral Questions (please select all that are relevant) *

• Is there an underlying health problem impacting on the student’s ability to undertake course work or placements?
• If Yes, how does it affect their ability? Please provide details
• If a health condition exists is it likely to be short term, fluctuating or permanent?
• Is there any likelihood that the clinical placement / environment may be contributing to the health problem? If so can you identify the relevant factors (physical, psychological or environmental)
• Is the student fit to undertake a full range of expected clinical placement duties?
• Are there any modifications / adjustments to suggest for consideration which may alleviate the health problem or facilitate the student’s clinical placement?
• Does the student have a condition which is likely to be covered by the disability provision of the Equality Act 2010?
• When do you expect the student fit to return to university study / clinical placement?
• Is the student fit to attend a misconduct or fitness to practice hearing?
• Is further Occupational Health review recommended? If Yes please provide a brief rationale and proposed date.

Further comments / information (please include information to ensure Occupational Health is fully informed including what adjustments – including theory adjustments – have already been made prior to referral to GO Health Services) *

I confirm that this referral has been fully discussed with the student * YesNo

Please provide details as to why consent was not discussed *

If this referral is for a School of Nursing and Midwifery student please confirm if they are happy for a copy of any reports to also be sent to the School's Inclusion Champions (not applicable if not a School of Nursing and Midwifery student) * YesNoNot Applicable

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SECTION 3: REFERRING PERSON DETAILS

Name *

First

Last

Designation *

Email Address *

Email

Confirm Email

Phone Number *

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Submit