Supervisory Referral Forms - University Of Rochester Medical Center (Page 2 of 3) in pdf

Supervisory Referral Forms - University Of Rochester Medical Center Page 2

UR Medicine EAP Supervisory (Job Performance) Referral Form

This form is to be completed by the supervisor initiating the mandated referral to

UR Medicine EAP. Once complete, this form is to be given to the HR

Representative with copies of written documentation related to any disciplinary

action taken. The HR Representative will contact EAP to initiate the referral,

forwarding the paperwork to UR Medicine EAP at FAX #475-9516. The

information gathered in this form is intended to serve as a guideline for

supervisors in articulating the nature of the problem and what is expected from

the employee and UR Medicine EAP in order to gain effective resolution. An EAP

appointment will be scheduled upon completion and submission of this form to

UR Medicine EAP and contact by employee.

Please note that the information provided here will be shared with

employee.

Date:___________________

Organization:_________________________________________

Employee Name _______________________________________

Referring Supervisor: _________________Phone:____________

Human Resources Rep. :_______________ Phone:____________

Secure Fax Number:

____________________________

Or Email

____________________________

(email correspondence will be sent via secure email)

Describe the job performance problem that prompted mandated referral to UR

Medicine EAP: (what happened, problem behaviors, duration of problem)

Describe past job performance:

Supervisory Referral Forms - University Of Rochester Medical Center Page 2