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Feeling overwhelmed?

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

HR SBA

People Leader

Other

(Select self-referral if you are filling out the form for yourself. If the employee's people leaders or HR SBA is completing the form, please ensure the employee is aware of this referral.)

If other, please indicate the name of the individual who completed this form

* 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 day worked before absence

If your last day worked was not a full day, please indicate how many hours you worked that day

First day absence began

Employee Information

Employee ID Can be found on your paycheque

* Employee Name

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

CUPE 1975

Exempt

Non-union Employees

Senior Leadership

USFA

Other

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

If other, please explain

College/Department

* Employee Type

Full Time

Part Time

* Work Schedule

Monday-Friday

Shift work and/or weekend work hours

* Position Type

Permanent

Temporary

Hours worked per week

If temporary, start and end date

USask Information

* Manager's Name

* Manager's Email

* Work Phone

Who is my HR SBA?

Human Resources Strategic Business Advisor (SBA)

SBA's Email

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

wellnessresources@usask.ca

Please ensure that you are not submitting confidential or sensitive information.

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