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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

Sick Leave or Short-term Disability - exceeding 5 days (Complete ALL sections below)

Medical Accommodations (Employee still at work)

Excessive Absenteesim Due to Medical Reasons

Other

If other, please explain

If sick leave or short-term disability

If absence exceeds 5 days

Last full day worked before absence

First day absence began

Benefit Start Date (first full day off)

Employee Information

Employee ID Can be found on your paycheque

* Employee Name

Gender

Female

Male

Gender Variant

Prefer not to say

Date of Birth

Job Title

Home Address

Street Address

City

Province / State

Postal Code/ZIP Code/Rural Route

Country

Work Phone

Home or Cell Phone (While on leave)

* Work Email

Email (While on leave)

* Employment Group

ASPA

Exempt

Non-union Employees

USFA

Other

CUPE 1975

If CUPE 1975, what is your sick leave balance (hours)

If other, please explain

College/Department

* Employee Type

Full Time

Part Time

* Position Type

Permanent

Temporary

Hours worked per week

If temporary, start and end date

USask Information

* Manager's Name

* Manager's Telephone

* Manager's Email

Human Resources Strategic Business Advisor (SBA)

SBA's Telephone

SBA'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 medical notes to accompany this form, please email them to wellnessresources@usask.ca

If you have any questions please contact Wellness Resources

(306) 966-4580
wellnessresources@usask.ca

University of Saskatchewan