How to fill out a referral for a preventive health check-up for an employee?

Before an employee undergoes a preventive health examination, the employer must complete an appropriate referral form, which is the key document for conducting the examination. There are two types of referrals: a referral for a preliminary examination, which is completed before starting work, and a referral for a periodic or targeted examination, which is used for regular examinations during employment or in special circumstances. Below, we will use the example of a referral for a preliminary examination to show in detail how to correctly complete the referral form to ensure that the examination is carried out properly and the employee's health status is accurately assessed.

Fill in the employer and employee details.

Circle the type of review and state the job title.

Indicate the date of preparation of the Safety Statement with risk assessment, if one has been carried out. Summarize the important data from the risk assessment - a brief description of the work process (e.g. The employee performs administrative work in an office environment. Preparing, archiving documents, making telephone calls. The work is carried out in one shift (morning), 40 hours per week.)

List work equipment (e.g. office equipment, telephone, computer, photocopier).

Specify the objects of the work (e.g. information).

In this section, list the risks at work (e.g. working with biological material, working on night shifts, working at heights, working with vibrations, driving for professional purposes, etc.).

Complete this section if measures have been implemented in the field of work protection and humanization.

Specify personal protective equipment, if used (e.g. earplugs, helmet, protective mask/coat, etc.).

To complete this section, you will be assisted by the medical part of the risk assessment prepared by an occupational physician (e.g. for night work, for driving for professional purposes, for working at heights, etc.).

It is stated if, from a safety and health perspective, a certain workplace is unsuitable for a specific group of people (e.g. minors, pregnant women, etc.).

In the employer's comments, you can provide additional information to the occupational medicine doctor. You can report any observations or problems that the employee may have in the work process. The latter will help in designing the review and final assessment, and implementing any possible measures.

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