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Wellness Referral Form

To assist Wellness Resources in providing services and supports when a health matter may be impacting an employee’s ability to work, please complete this Wellness Resources Referral Form including any medical notes received.

Form Successfully Submitted

* Date of Referral

* Referred by

Self Referral

Other

(If this is not a self-referral, please ensure the employee is aware of this referral.)

If other, who referred you

* Reason for Referral

Extended Medical Absence - exceeding 5 days (Complete ALL sections below)

Medical Accommodations (Employee still at work)

Wellness Consultation

Other

If other, please explain

Employee Information

* Employee ID

* Email (While on leave)

* Telephone (While on leave)

Date of Birth

Gender

Female

Male

Gender Variant

Prefer not to say

Job Title

College/Department

Is employee still working?

Yes

Additional Employee Information

To be completed if employee is (or will be) absent from work due to medical

Please attach the employee’s job profile or job positing and the position Physical Demands Analysis (PDA), if their position has a PDA.

Please attach any additional medical notes.

Last full day worked before absence

First day absence began

Date of Hire

* Employment Group

ASPA

USFA

Exempt

CUPE 1975

Other:

If CUPE 1975, What is your Sick Leave Balance

If other, please explain

Employee Type

Full Time

Part Time

If Part Time, what is your FTE

Position Type

Permanent

Temporary

If temporary, start and end date

Has employee returned to work?

Yes

If Yes, indicate date returned

If no, is a return to work date known?

Yes

Anticipated date of return

Employer Information

Manager's Name

Manager's Telephone

Manager's Email

Human Resources Strategic Business Advisor (SBA)

SBA's Telephone

SBA's Email

Who is accountable for processing your unit’s payroll actions (EJS’s)

ConnectionPoint

Other

If Other,

Telephone

Do you know why the Employee is currently absent?

Yes

Unknown

If yes, please provide details

Additional Information

Are there any additional comments or related issues to this referral

If you have any questions please contact Wellness Resources

(306) 966-4580
wellnessresources@usask.ca

University of Saskatchewan