ࡱ> pso] N7bjbj~]~] ~7i7i^ TT@(=UUUU ##L#('''''''$),'Q$"" #$$'UU 'W&W&W&$ UU'W&$'W&W&W&U $@W&o'(0@(W&-$v-W&-W&$*$W&8$ D$Y$$$'']%$$$@($$$$-$$$$$$$$$ Y G: UCL HUMAN RESOURCES DIVISION WORKPLACE HEALTH SELF REFERRAL FORM - STRICTLY CONFIDENTIAL Once completed please email to: HYPERLINK "mailto:wh.occupationalhealth@ucl.ac.uk"wh.occupationalhealth@ucl.ac.uk Surname: FORMTEXT       Title:  FORMTEXT       First name: FORMTEXT      Department & address: FORMTEXT       Date of Birth: FORMTEXT      Gender: Male  FORMCHECKBOX  Female  FORMCHECKBOX  Other  FORMCHECKBOX  Telephone numbers:Mobile: FORMTEXT       THIS FIELD IS MANDATORY  Workplace Health team will call to arrange the appointmentEmail address: FORMTEXT       The Occupational Health service provides advice for staff and managers on adjustments to work to prevent or reduce the risk of work related health problems. For treatment, investigations or specialist referral, you need to consult your GP as we are unable to offer these services. Note that short term physiotherapy is available via this referral. Please state the reason you wish to self refer to Occupational Health (OH). If you have concerns about your computer and desk set-up, a Work Station Assessment should be completed by your Departmental Safety Officer (DSO) before coming to OH. Please bring a copy of the report with you. Reason for referral:  FORMTEXT :<>ٵٸ<+ h Lh6ECJOJQJ^JaJ he9ah6ECJOJQJ^JaJ$h6Eh#B*OJQJ]^Jph'h6Eh#5B*OJQJ]^Jphhh[{5OJQJ^Jhh[{5>*OJQJ^J h-h#CJOJQJ^JaJ#h6Eh#5CJOJQJ^JaJ#h6Eh6E5CJOJQJ^JaJ#h-h!5CJOJQJ^JaJ#h-h#5CJOJQJ^JaJ(jh-hdCJUaJmHnHu<>`bdf f 8 $Ifgdz3: x$Ifgdz3: $Ifgd#gd#xxgd6E$a$gd# b d d ۷ۥujXuCCCCCujj(jh `hz3:CJUaJmHnHu#jh `hz3:CJUaJh `hz3:CJaJjh `hz3:CJUaJh `hz3:56OJQJ^J h-h#CJOJQJ^JaJ#h6Eh#CJOJQJ]^JaJ$hA h6E0JCJOJQJ^JaJ hA h6ECJOJQJ^JaJ)jhA h6ECJOJQJU^JaJh6E5CJOJQJ^JaJd f p t v 6 8 : D F H N P R ֳƞwgWwGwh `ho56OJQJ^Jh `h56OJQJ^Jh `h&@256OJQJ^Jh `h/`56OJQJ^Jh `hz3:CJaJh `hz3:5CJaJ)jhz3:5OJQJU^JmHnHu$jthz3:5OJQJU^Jjhz3:5OJQJU^Jhz3:5OJQJ^Jhz3:hz3:5OJQJ^J h `hz3:CJOJQJ^JaJ8 : R z \SS $Ifgd#kd$$IflF `'`  t0'6    44 lapytz3:R T h j l n p r t v x z | 𾾾𳳣~mU~:::4jh `hMBCJOJQJU^JaJmHnHu/jh `h;HCJOJQJU^JaJ h `hMBCJOJQJ^JaJ)jh `hMBCJOJQJU^JaJh `ho56OJQJ^Jh `h/`56OJQJ^Jh `h#CJaJ(jh `hMBCJUaJmHnHu#jh `h;HCJUaJh `hMBCJaJjh `hMBCJUaJz | tk`kk x$Ifgd ` $Ifgd#kd!$$Ifl0 `'` l t0'644 lapyt `         , : пqVVVVVIh `hoOJQJ^J4jh `hoCJOJQJU^JaJmHnHu/jh `hoCJOJQJU^JaJ)jh `hoCJOJQJU^JaJh `ho56OJQJ^J h `hoCJOJQJ^JaJ h `h#CJOJQJ^JaJ)jh `hMBCJOJQJU^JaJ4jh `hMBCJOJQJU^JaJmHnHu  tkkk $Ifgd6kd@$$Ifl0 `'` l t0'644 lapyt `: < X Z \ p r   $ ᯢ}ll\O>O!jh `h6OJQJU^Jh `h6OJQJ^Jh `h656OJQJ^J h `hoCJOJQJ^JaJ'jIh `hhaOJQJU^J!jh `hhaOJQJU^Jh `hhaOJQJ^JhhaOJQJ^J'jh `hoOJQJU^J'j]h `hoOJQJU^Jh `hoOJQJ^J!jh `hoOJQJU^J 6 \QDD xx$Ifgd ` x$Ifgd `kd$$IflF 4`'` @ , t0'6    44 lapyt `$ & ( * , . 0 2 4 6  "$&(*,:ZڹvbړPvv#h `h65CJOJQJ^JaJ'jh `h6OJQJU^Jh `h6OJQJ^Jh `h656OJQJ^J h `h6CJOJQJ^JaJ)h6Eh6EB*CJOJQJ^JaJphh6OJQJ^J,jh `h6OJQJU^JmHnHu!jh `h6OJQJU^J'jh `h6OJQJU^J (tg^ $Ifgd6 xx$Ifgd `kd$$IflN0 `'` l t0'644 lapyt `(*,fhsttk_____ $$Ifa$gd ` $Ifgdskd$$Ifl0 `'` l t0'644 lapyt `Zfhst22222 2 2222v3x344ǹ|zcccccYOh6OJQJ^JhOJQJ^J,jh `h6EOJQJU^JmHnHuU'jI h `h6EOJQJU^Jh `h6EOJQJ^J!jh `h6EOJQJU^Jh6E5OJQJ^Jh `h65OJQJ^J h `h6CJOJQJ^JaJh `h6>*OJQJ^Jh `h6OJQJ^Jh `h1OJQJ^J2245xjj$x$Ifa$gdHh $Ifgds x$Ifgd `skd$$Ifl `'' t0'644 lap yt `      As a  self-referral a report will not be generated as a result of your meeting with OH. For a report to your manager regarding adjustments to work to be generated, please ask your manager to complete a  management referral form which can be found HYPERLINK "https://www.ucl.ac.uk/human-resources/health-wellbeing/what-we-do/manager-referrals-workplace-health"https://www.ucl.ac.uk/human-resources/health-wellbeing/what-we-do/manager-referrals-workplace-health Have you consulted your GP?Yes  FORMCHECKBOX  No  FORMCHECKBOX  Signed:  FORMTEXT       Date:  FORMTEXT       444444555555$6&6B6D6F6666666666羭{gYKhphwk6OJQJ^JhoCJOJQJ^JaJ'j h `h6OJQJU^J'jJ h `h6OJQJU^J!jh `h6OJQJU^Jh `h6OJQJ^J h `h6CJOJQJ^JaJh `hHhOJQJ^JhIh6E0JOJQJ^Jh6Eh6EOJQJ^Jh6EOJQJ^Jjh6EOJQJU^J5556v $Ifgd# xx$Ifgd `skd $$Ifl\`'' t0'644 lap yt6E666N7vqqgd#kd4 $$Ifl0`'|P t0'644 lapyt `66666666666666666777"7$7&7(7<7>7@7B7D7F7H7J7L7N7ȴ՝ȏ揁t`՝t'jO hh_OJQJU^JhhwkOJQJ^Jhpho6OJQJ^Jhph6OJQJ^J,jhh/OJQJU^JmHnHu'j hh_OJQJU^Jhh/OJQJ^J!jhh/OJQJU^Jhphwk6OJQJ^Jhp6OJQJ^J!21h:pl. A!n"R#S$S% n>"{*,WBPNG  IHDR h= pHYs.#.#x?vgAMAOX2tEXtSoftwareAdobe ImageReadyqe<>%IDATxб @3fTu3W,vB ;z;S6^t۱ YFhi(P&q'y\`M*K Zط@+B1‹ H3`ss9bŐۑwY_ػ@ Qhtݏ`9=X3Hl{څO[|w' E]yC`AZI߱ƥ۹!TVz>lTP+G 6 w-~M4\۽Q|T PhhNR+gGZ)Ҽ&{w CGfk"  R֏(Ynx>W4ű|^;e0ղ6o&0ɳٲғ;鳧5ď$̪wrޕ8(;?ʻ켢<>`mAjH];z[V-̊ïf=n5z& `ߎmA:*n`bl.Zp7NKyVc,¬=Zb9-ػ`)R|ZXNTOI5+>{Y4Chϛ>){wp@̎&BoM8Npì5k ޖBʹi-? 0yf]vH|ae-żs-UiaJ̗WuI `]j2Zl>ޕډZ0 'ة6YT e(Zݏ6-=ػc@hnjZܕQ}^@ >1iӚuW= fIɵn֙k @\:ZCRAՑ;z9"fj֖UޚV4'J s`Ma :?)v,$ Yȩx-1j_juq nA1 УU7h44H69|-h@Aބ|mgO+]͢l_Y"|` 0sLZEطbj&!K+g[#.sLZEط"a֑>]fi, 0 e-`wz'gH ;("ਬvp7^h0ª8Xy{*bۡ E:ZGoHBNVV|Z<8H `{G]VWw8 E=s&Wi-R0DZ}Y0jCQ>};& fҋte~;KاiB};(z6o75P"ɍB Z~֏G6m8Ʒ،EZ-طcA$l1%TH5ޡE2k1! 0Eg`MA( hhiBRޕ: uh\^%xo 0d4Fc(C#-W-c.Htw(0~şi_O3 RԻCӡ%!C+LJ^w,i\Ϗ-VZH \aeXp? +ٶy SHHMojss @MGs3WAQ BI&!-|]I{_ShW_aϛ A6S ՐVp{Q`m (hXX(]BBCZV{_oxe iN'\k}r}Ƹ:jiw(04i6:HdME$D2GQgZ܁ļ\˶=39mlp|ޡ]SVNuػA eѤB=Jxh.(c2D:~~ dMWg=M?{Ylwr4ػwB W$jiݙ@#qƕ!'k Xڹouy~s>sqKA Уe7fy]"A{+w Z|B gI<#KKZ{hk,zlӊH\]V+{w9`Na ZYJ;>D|T6J^Wi~s\)Cr+;ڋ9=}us=w P PZG+B Z!P=pq8d'Zǰ0yp5l$jY = o; jrouj w dQzGhZh(e mca63"cօҨ2}]wFG`S;HẒy4;Y50(Bqqi"+'1Qsx3G5 O3d3Y?jɕh{*ڴv%ElZtػA =̧J)!4f.^qY.NB@kmӘ srAq,,ЪYAd^2Vzi*܍鎛s]Τߴ>ㇹR{OA7#A g}Z2sDe5h7Y EP)!Sy->eM++CVyOƬ>k5U|w( @=Z]@> hT ,lǮoQќ;kf`MA( h=$X];x(:gCgC%`Qa^ݣh `U0Gm/{t=>HbRls"쌍YlػC`T5IQ H :==gmGNlS%u`ߎia( Z4!l l~ O67kgME1Emfa<QQQ1IGVVi o&0EWh&E$Z-kT-j~YoJطc@ YY`"L ǥ+22۵};qiIѯzw6 EWhjNPMHs?nKD2V=k}/dvxo60h'$w_?pCLwETB\iOv? Zf-BU2zC,z2ݱ ZP[!NgV,;6a [["w]x"^mC6./Z,:)vlp5Gc4G3FtwhrsxOɴ. Yw8 󴩙 wjhΗC%-,۱ 0 Ibm挞>,])߽e]'-j=dQ*6_bطcA )\#JFs4Gv"\'(Bh='GŨ1伯Hd*ηW` @t4Gs4Ghe-@BxQ-Dtm7z֭$z56`!vl 쵞i={bQ8hΗJZB몍:fzw60aVc46&HPܕ.,`قWoR'rg}whS zD#;tL(W5 8@A^طc `ͬE"i$w;h/=1IR 娚UOKaWHC!i%A `/  |> IA܈A 0* i:EHLrq!_`_ `'vl5N@3 T{fOQqi}; |aP8"qgߓX$3uXJطcA[[bA HF  H@a@/5hgVطC#b1+08.q/.*vd'j_Fطc9ZFw!p}>ZtLVطcAs] ZSoê?!loxVطC`bu5F-,#Il?+L\o簻<`ߎ[awy$hL  H@X`vG۱ 9.-)طC`bjGbIx9RY` oE4J"ߠDM`ߎ[awy$hL  H@X`vG۱ 9.-)طc;ZFw!p}>ZrzLVطc"ae!.DBT?VطcAs] ZSo簻<`ߎ[awy$hL  H@ `祀Ux ,$wנl) f~TnjطC#@4RjB#(ʗA xRsLʵ H@X`vG۱ 9.-)طc;ZFw!p}>ZrzLVطc"ae!.DBTVطC`bj#IlԌ/M\oD ĔJ: wߠL;~TiطC1zGóirA GNI  i $3hlDWطcaaSɆ?-S$8 @l$i1ޞ-`T˶Cا`j@ 8# $g8ГR[طcaJ) |$נ|oF Vc4Fc4<;&q/rpZ0};&aTj w1qxUbOJ:o&0 ^鹡% -$nQ ~Q=@| 3-`%~>Z۱ IBFI ] rEy;Q_}؄Zۡ @(('$̌; d,;5@ 0t!D$|A  I~ mˎZ4%vh@Ct5،`;A9k h7P+9ŞoRycNP m@ė4rH]-_Ɉ-y1sGos/j-FQDxS;()A w(hO]JO>̴!C߆}!H1ߦp@,45q]nsmCoPtS]7cp(b6l;hlٌ 9R(Bt-k^cE+x5zpŴ<=Gڃ-Z$ᬻQ `&v0PjLI`yos}HfvTqEC\=zwۼ˂gx3V/n6~^`Qa(7frR(Rxos33Q@ Z͑BZV>N 1!5{7l'xsT-g[ f=;vᬩ j .ػ( )RY"?)El<\M]O(ιO9hYh 㲚Y[w40F ! ,4o/h匹% zކ=E7CP};\,ҊA H2iQczkI^:NطC}iy@2#)P+.pi8kV+iDZ\ڋ~8 `/{wl BQp{mw#H1YCMsi/n2]طc`bf${T'Ni8k|2DZًg`qa > 0PId6V|OEu8Cib/^mطs`C$L mvZjlB0i[7^^`Qa 4lJPS%-V_Jl'n)(qr׭ˋ3[l M , ~F:g қݾ@ "jVMp"Iu>HKᭈb{Q;ݱ P PWa4F C4Q^G Wâԇ~&ɗr5aC=v@Y^#Up O͊l)~C `~B%f Q/_\d*!ȉݱ ;hVn'ʓ!c5<\dvav 8V)g`nA Z`$T- ݞ9b ^ .r~{?K `ߎMa "8FB7/)@3F3ԉF| 0|GOIENDB`tDText9vDText32$$If!vh#v` #v#v :V l t0'6,5` 55 pytz3:vDText10$$If!vh#v` #vl:V l t0'6,5` 5lpyt `vDText11$$If!vh#v` #vl:V l t0'6,5` 5lpyt `tDText5vDeCheck11vDeCheck12vDeCheck12$$If!vh#v` #v@ #v,:V l t0'6,5` 5@ 5,pyt `vDText31$$If!vh#v` #vl:V lN t0'6,5` 5lpyt `vDText21$$If!vh#v` #vl:V l t0'6,5` 5lpyt `$$If!vh#v':V l t0'65'p yt `vDText21$$If!vh#v':V l\ t0'65'p yt6EtDCheck9vDeCheck10$$If!vh#v|#vP:V l t0'6,5|5Ppyt `vDText26vDText27x2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH DA D Default Paragraph FontRi@R  Table Normal4 l4a (k (No List jj # Table Grid7:V0HH C> Balloon TextCJOJQJ^JaJB' B SGComment ReferenceCJaJ<"< SG Comment TextCJaJ@j!"@ SGComment Subject5\6U`A6 6 Hyperlink >*B*phFV QF zVFollowedHyperlink >*B* ph4>@b4 6ETitle$a$CJtH 8/q8 6E Title Char CJaJtH Rv!R 6E0Unresolved MentionB*ph`^\q PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V (BO)MBT.$@0H!A>풠Uc-zD[&!rX=}zC0` ި%.]Ssd--7 +fOZեrŵVœ\lji2ZGwm-3˵j7\ Uk5FҨ-:xRkcr3Ϣ+9kji9OP Et-j|#p;E=Ɖ5Z2sgF=8 K}*7c<`*HJTcB<{Jc]\ Ҡk=ti"MGfIw&9ql> $>HmPd{(6%z:"'/f7w0qBcF6f Iöi1(\}B5ҹ~Bcr6I;}mY/lIz1!) ac 1fm ƪN^I77yrJ'd$s<{uC>== Ƌ(uX=WA NC2>GK<(C,ݖm: &-8j^N܀ݑ$4:/x vTu>*ٞn{M.Ǿ0v4<1>&ⶏVn.B>1CḑOk!#;Ҍ}$pQ˙y')fY?u \$/1d8*ZI$G#d\,{uk<$:lWV j^ZơSc*+ESa1똀 k3Ģxzjv3,jZU3@jWu;z \v5i?{8&==ϘNX1?  O4׹ӧCvHa01 %xz24ĥ=m X\(7Xjg !Ӆqd? cG7.`~w*?, 2 nN*"Fz_&n &\ F:l[+%f ^,@d R : $ Z46N7 8 z (56N7 ~:FL -8HSc * "(JV\^XFFFFFG$G$G$FFFXG$G$FF,b$"{*,WB>4@5 0e0e     @ 5% 8c8c     ?1 d0u0@Ty2 NP'p<'pA)BCD|E||s " 0e@        @ABC DEFGHIJK5%LMNOPQRSTUWYZ[ \]^_ `abN 5%  N 5%  N    5%    !"?N@ABC DEFGHIJK5%LMNOPQRSTUWYZ[ \]^_ `ab@(  x  C :A"? UCL open small_1"?B S  ?^*t@ Text9Text32Text10Text11Text5Check9Check10Text26Text27;K`M  )]`<( ``?*urn:schemas-microsoft-com:office:smarttags stockticker `:M]`/g]`/^2:LiLMrs  `@?C>7@HA6E;HtH+OHS7UzVjMiwk'>p[{jsNz")d>!NHTBpC! `6o/`MBHhX=-ShaS+R|_l^`@ SdSSL^   @2UnknownG.[x Times New Roman5Symbol3. .[x Arial5. .[`)TahomaC. Aptos Display3. AptosA$BCambria Math"h‡3L&??!nS0ZZ 2q@P ?+*!xxJ. BE:\Temporary Internet Files\OLK8F\selfreferralformupdate231109.dotUCL HUMAN RESOURCES DIVISIONuczuanfGasiorek, Ania Oh+'0$ <H h t   ӰԺ HUMAN RESOURCES DIVISIONuczuanf selfreferralformupdate231109Gasiorek, Ania6Microsoft Office Word@^в@,Ul@܊e@ ӄ? ՜.+,D՜.+,P  hp   ӰԺ, ADSZ ӰԺ HUMAN RESOURCES DIVISION Title  `BJ~    _PID_HLINKS_TentativeReviewCycleID_ReviewCycleID_NewReviewCycle_EmailEntryID_EmailStoreID_ReviewingToolsShownOnce _EmailStoreID0 _EmailStoreID1A H!ehttps://www.ucl.ac.uk/human-resources/health-wellbeing/what-we-do/manager-referrals-workplace-healthB{'mailto:wh.occupationalhealth@ucl.ac.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`abcdefhijklmnqruRoot Entry FtData @1TableH-WordDocument ~SummaryInformation(_DocumentSummaryInformation8gMsoDataStore 2I0OECRQ==2 Item  PropertiesUCompObj r   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q