What this is
What is a health referral record?
What is a health referral record?
A health referral record documents a referral of a worker to occupational health: who is asking, why, what specific questions need answering, and what background information has been given. It is distinct from the outcome, a fitness opinion and any recommended adjustments, and from the underlying clinical detail, which stays with occupational health.
Who raises a health referral?
Usually the worker's manager, following an absence trigger, a return to work, or a health surveillance finding. A worker can also self-refer. Either way, the record makes the referral traceable and holds the confidentiality barrier in place from the point it is raised.
How is this different from the clinical outcome?
The referral record captures the request: the reason, the questions, and the supporting information sent. The outcome is a fitness opinion, with restrictions and duration if relevant. The diagnosis and clinical reasoning behind it are not part of this record and are not disclosed to management.
Scope
When is a health referral record required?
This record is one step in a larger programme. Using it for work that belongs to a neighbouring template produces records that are hard to report on later.
Use this template when
- A manager needs an occupational health opinion on a worker's fitness for a task, before or after a change
- A worker is returning from absence and a capability opinion is needed before they resume full duties
- A health surveillance finding or an absence pattern triggers a referral for further assessment
- A worker self-refers because they are concerned about their own fitness for a task
- A previous referral's follow-up condition has been reached and a further opinion is required
Do not use it for
- Health Surveillance Plan, which sets out which workers need which health checks, how often and why, rather than a one-off referral for an individual concern.
- Pre-Placement Health Assessment, which assesses whether a worker can safely perform a role's physical demands before they start, not after a concern has arisen.
- Periodic Health Assessment, a scheduled health check for workers exposed to specific hazards, run on a cycle rather than triggered by an event.
- Exposure Incident Record, which documents an acute, unplanned exposure event where a treatment window drives the process, not a planned referral.
- Anything outside KnowHealth, which belongs in the workspace that owns that process.
Compliance mapping
Which Privacy legislation requirements does this satisfy?
Privacy legislation does not prescribe a referral form. It constrains what may be collected, who may see it, and on what basis, and those constraints are what shape a defensible referral.
| Clause | Requirement | Where it lands |
|---|---|---|
| GDPR Art. 9(1) | Health data is special category data, processed only under specific conditions and with appropriate safeguards | Header |
| GDPR Art. 9(2)(h) | Processing permitted for assessment of a worker's working capacity, subject to confidentiality obligations owed to the data subject | Header |
| GDPR Art. 5(1)(c) | Data minimisation: only the fitness outcome and restrictions needed by management should be shared, not the underlying clinical detail | Advice received |
| GDPR Art. 7 | Consent, where relied on, must be freely given and specific, and withdrawal must be as easy as giving it | The referral |
| GDPR Art. 15 | The data subject's right of access supports giving the worker a copy of what was sent about them | The referral |
| Equality Act 2010 s.20 | The duty to make reasonable adjustments depends on the employer knowing what would help, which the referral's specific questions are meant to surface | Advice received |
| UK DPA 2018 Sch.1 Part 1 para.2 | Employment-related processing of health data requires a policy basis and a necessity test, not blanket collection | Header |
What it does not cover
- Exposure Incident Record, raised immediately after an acute exposure event and driving urgent treatment, not a planned referral for a considered opinion.
- Health Surveillance Plan, which sets the schedule of routine checks a role requires, independent of any individual concern.
- Pre-Placement Health Assessment, completed before a worker starts a role, not once a concern has already arisen.
- Periodic Health Assessment, the scheduled check itself, not the record of why one worker was sent for an additional opinion.
- The occupational health report, which holds the clinical reasoning and stays with occupational health, not in a record visible to management.
Global
Health Referral Record requirements by country
The duty to protect health data at a referral is close to universal. What differs is which instrument does the work, and how directly it reaches the referral itself.
Americans with Disabilities Act; state privacy and medical confidentiality law
Medical information from an employment-related examination must be kept in separate, confidential files, with disclosure to managers limited to necessary restrictions and accommodations.
A referral surfacing diagnosis to a line manager, rather than restrictions and duration, is the pattern the ADA's confidentiality requirement targets.
UK GDPR, Data Protection Act 2018, Equality Act 2010
Health data is special category data requiring a lawful basis and a specific condition; the reasonable adjustments duty depends on the employer knowing what would help.
The referral is where these two meet: specific enough to surface adjustments, while restricting what comes back to what the employer needs.
GDPR (as adopted or mirrored across the EEA and beyond); ILO guidance on the confidentiality of workers' health data
Processing of health data for assessing working capacity is a recognised exception to the general prohibition on special category data, conditioned on confidentiality safeguards.
Wherever deployed, the same test applies: is this processing necessary for the referral's purpose, and is access limited to those who need it.
How to complete it
How to complete a health referral record, step by step
Most referrals are written to get a form off a manager's desk. The parts that determine whether the referral produces a usable answer are the ones a template does not force.
A referral asking whether somebody is fit for work produces a useless answer, because fitness is rarely binary. Ask what the worker can do, what adjustments would help, and for how long. Those three questions let a manager actually plan a return to work.
An opinion on fitness cannot be formed without knowing what the job involves. Job demands, and the risk assessment where one exists, should go with the referral. Giving occupational health only a name and a vague reason forces them to guess at the demands they are weighing against.
State plainly, on the record itself, that clinical detail stays with occupational health and management receives a fitness outcome and restrictions only. This is what makes the worker's consent meaningful, and it is the line that gets crossed when a manager and an adviser have an off-record conversation.
A referral the worker does not know about is where trust in the process breaks down. Confirming the worker is aware, obtaining consent, and giving them a copy turns the referral from something done to them into something done with them.
What auditors find
Most common health referral record findings
A health referral record is unusual in that the document almost always exists once occupational health is involved. The findings concern what it actually asks and who ends up seeing what.
| Finding | Clause | What fixes it |
|---|---|---|
| Referral asks a binary fitness question instead of what the worker can do and for how long. | Equality Act 2010 s.20 | Rewrite the specific questions to name the task, the demand, and the duration in question. |
| Job demands or risk assessment not provided, so occupational health assesses fitness in the abstract. | GDPR Art. 9(2)(h) | Attach the job demands and risk assessment before the referral is sent, not after occupational health asks for them. |
| Worker not aware of the referral, or consent not obtained, before it is sent. | GDPR Art. 7 | Confirm awareness and obtain consent as a gate before the referral leaves the manager's hands. |
| Access to clinical detail is only partly restricted, so a manager can see more than the fitness outcome. | GDPR Art. 5(1)(c) | Restrict access controls to occupational health for any field carrying clinical detail; verify, do not assume. |
| Worker not given a copy of the referral that was sent about them. | GDPR Art. 15 | Issue the worker a copy at the point of referral, not on request after the fact. |
| Follow-up referral needed but not linked to the case that triggered it. | Standard-specific | Record the case reference on the follow-up referral so the chain of decisions stays traceable. |
Case in point
Case in point: the referral that answered a question nobody asked
A warehouse worker returned from six weeks of absence following surgery. The manager, wanting a quick answer before the shift rota was published, referred her with a single question: is she fit for work? Occupational health replied yes, with a note recommending a phased return that the manager did not read as a condition.
Within a week she was back on full manual handling duties, aggravated the injury, and the case went to a second, urgent referral. That one asked what she could lift, for how long, and what would need to change over the following month. The answer let the manager build an actual phased rota, which the first yes-or-no answer had never allowed for.
The template
The template, field by field
The form exactly as it installs. Every field, option, score and conditional rule is editable, and the links to other templates come with it.
4 sections
- Reference
- HLT-013
- Archetype
- Record
- Record ID
- HREF-2026-000
- Scoring
- Not scored
- Direction
- n/a
- Singleton
- No
- Basis
- Privacy legislation
- Links
- Links Worker
- Tags
- Health, Case
- Sections
- 4
- Fields
- 44
- Follow up fields
- 0
- Repeating sections
- 0
- Links out
- 6
Header
16 fieldsReferral ID*
Auto sequence. Format REF-2026-000.
The record's own ID. Other templates point at this value.
Status*
Drives who this goes to next.
- Planned2 pts
- In progress2 pts
- Complete3 pts
- Deferred0 pts
- Open0 pts
- Closed3 pts
- Overdue0 pts
Date and Time*
Completed By*
Site*
Site ID*
Format SITE-000.
Links to FDN-001 Site ID
Worker*
Person ID*
Format PER-0000.
Links to FDN-003 Person ID
Record Confidentiality
Clinical detail stays with occupational health. Management receives a fitness outcome and any restrictions, never a diagnosis. Restrict access to this template accordingly.
Clinical Detail Held Separately*
- Yes3 pts
- No0 pts
Access Restricted To Occupational Health*
- Yes3 pts
- Partly1 pt
- No0 pts
Worker Consent Obtained*
Consent to share the fitness outcome with the employer. Withdrawal is the worker's right.
- Yes3 pts
- No0 pts
Referral Source*
Manager, self referral, health surveillance, return to work or absence trigger.
Referral Urgency*
Date Referred*
Ask A Question You Can Act On
A referral asking whether somebody is fit for work produces a useless answer. Ask what they can do, what adjustments would help, and for how long.
The referral
10 fieldsReason For Referral*
Specific Questions Asked*
What the manager actually needs answered to make a decision.
Task
Job ID
Format JOB-000.
Links to FDN-004 Job Task ID
Job Demands Provided*
Occupational health cannot advise on fitness without knowing what the job involves.
- Yes3 pts
- Partly1 pt
- No0 pts
Risk Assessment Provided*
- Yes3 pts
- No0 pts
Absence History Provided
- Yes3 pts
- No1 pt
Worker Aware Of Referral*
- Yes3 pts
- No0 pts
Consent Obtained*
- Yes3 pts
- No0 pts
Worker Given Copy Of Referral*
- Yes3 pts
- No0 pts
Appointment
5 fieldsAppointment Offered Date
Appointment Attended
- Yes3 pts
- Rescheduled1 pt
- Did not attend0 pts
Days From Referral To Appointment
Provider
Assessment Type
Advice received
13 fieldsReport Received
- Yes3 pts
- Awaited1 pt
- No0 pts
Days To Report
Questions Answered
- Fully3 pts
- Partly1 pt
- No0 pts
Fitness Outcome
- Fit3 pts
- Fit with restrictions2 pts
- Temporarily unfit1 pt
- Unfit0 pts
Adjustments Recommended
Expected Duration
- Under 2 weeks3 pts
- 2 to 6 weeks2 pts
- 6 weeks to 3 months1 pt
- Over 3 months0 pts
- Indefinite0 pts
Case Record ID
Links to HLT-016 Case ID
Restriction Record ID
Links to HLT-017 Record ID
Follow Up Referral Needed
Referring Manager*
Signature*
Occupational Health*
Second Signature*
HLT-013 · record IDs look like HREF-2026-000 · Links Worker
Open in KnowellaRun it with agents
From a document you fill in to a programme that runs itself
The form is the easy part. Keeping it current, routing it to the right owner and holding the evidence together is the work that actually slips.
Holds the referral library against the worker and case registers, enforces the confidentiality barrier on clinical fields, and routes each referral to its owner.
Links a referral back to the risk assessment or incident that triggered it, so occupational health receives the job context rather than a name alone.
Coordinates the crew, rolls referral status and follow-up due dates into one view, and holds every write for your approval before it touches a record.
This template lives in KnowHealth — employee wellbeing. Exposure monitoring, health surveillance, case management and return to work.
Meet KnowHealth→Glossary
Health Referral Record definitions and key terms
- Occupational health referral
- A request from an employer, or a worker, for occupational health to assess a specific question about fitness, capability or adjustments.
- Fitness outcome
- The conclusion occupational health returns to the employer: fit, fit with restrictions, temporarily unfit, or unfit, without the clinical reasoning behind it.
- Reasonable adjustment
- A change to a role, workplace or arrangement that removes or reduces a disadvantage a worker would otherwise face, which the referral's specific questions are meant to surface.
- Special category data
- The GDPR term for data including health information, which may only be processed under specific conditions and with additional safeguards.
- Confidentiality barrier
- The access restriction that keeps clinical detail with occupational health and limits what management sees to a fitness outcome and any restrictions.
FAQ
Frequently asked questions about health referral record
What should a referral actually ask?+
What the worker can do, what adjustments would help, and for how long, framed against the specific task or role in question. A referral asking only whether someone is fit for work gets a technically correct answer a manager cannot plan around.
Does the worker have to consent to the referral?+
The worker should be aware of and, in most practice, consent to the referral itself. Separately, consent governs whether the fitness outcome is shared with the employer at all, and the worker can withdraw that consent.
Who sees the clinical detail behind the fitness outcome?+
Occupational health only. Management receives the fitness outcome and any recommended restrictions or adjustments, never the diagnosis or the clinical reasoning that produced them.
Why does the referral need the job demands?+
Because fitness is relative to a task, not an abstract state. Occupational health cannot weigh a worker's capacity against a job's demands without knowing what those demands are, which is why job demands and, where relevant, the risk assessment should travel with the referral.
How is this different from an exposure incident record?+
A health referral is planned and non-urgent: a manager or worker asking for a considered opinion. An exposure incident record documents an acute, unplanned event, such as a needlestick or splash, where a narrow post-exposure treatment window drives the process instead.
Can the worker see what was sent about them?+
Yes, and good practice is to give them a copy at the point of referral rather than waiting for a data access request. It also tends to make the process itself more trusted, since the worker knows exactly what was asked and why.
Keep going
Related templates and programmes
Industries this is written for
Programmes this belongs to
Used together in Occupational Health Surveillance
Similar Exposure Group Register
Groups workers who share the same tasks, agents and exposure patterns
Qualitative Exposure Assessment
Rates likely exposure using professional judgement, task knowledge and existing data, before any sampling
Personal Air Sampling Record
Records a sample taken from a worker's breathing zone over a shift
Area Monitoring Record
Records fixed point sampling in a work area rather than on a person
Noise Dosimetry Record
Records a worker's noise exposure over a full shift using a personal dosimeter
Chemical Exposure Assessment
Assesses exposure to a specific chemical across the tasks where it is used
More in Health Surveillance
Health Surveillance Plan
Sets out which workers need which health checks, how often and why
Pre-Placement Health Assessment
Assesses whether a worker can safely perform the physical demands of a role, before they start
Periodic Health Assessment
A scheduled health check for workers exposed to specific hazards
Exit Health Assessment
Records a worker's health status when they leave a role with hazardous exposure
Vaccination Record
Records vaccinations offered and given where a role carries biological risk
Health Surveillance Compliance Review
Checks that scheduled health assessments are actually happening on time
Written and reviewed by
Siddarth Singh
Founder & Chief Executive Officer, Knowella
Certified Safety Professional and industrial and systems engineer with more than a decade inside food supply chain, freight and manufacturing operations. This page was written against the current text of the standards it cites, not against secondary summaries of them.
- Certified Safety Professional (CSP), Board of Certified Safety Professionals
- MBA, University of Chicago Booth School of Business
- MS and BS, The Ohio State University, Industrial and Systems Engineering
- Six Sigma Black Belt
Sources and last review. Reviewed 16 August 2026 against:
- UK GDPR and Data Protection Act 2018, Schedule 1, Part 1 (health data conditions)
- Equality Act 2010, section 20 (duty to make reasonable adjustments)
- Americans with Disabilities Act, confidentiality of medical information provisions
- ILO guidance on the protection of workers' personal data
This page is general guidance, not legal advice. Confirm requirements with your jurisdiction’s regulator.