Supervisor Referral Report Form Supervisor Referral Report Supervisor Referral Report Date of Referral Report * Employee Information Employee's Name * Employee's Date Hired * Employee's Job Title * Employee's Department * Employee's Phone * Employee's Email * Employee's Address * Employee's Address Employee's Address Employee's Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Supervisor Information Supervisor's Name * Supervisor's Job Title * Supervisor's Phone * HR Business Partner * Supervisor's Email * Reason(s) for Referral Please complete all of the sections below, basing your responses on the employee’s performance in the past 3 months. Please rate severity of the problem using the following scale ranging from 1-5. 1 = little or no problem, 2 = troublesome, 3 = somewhat severe, 4 = moderately severe, 5 = extremely severe Performance Problems * 1 = little or no problem2 = troublesome3 = somewhat severe4 = moderately severe5 = extremely severe missed deadlines, frequent mistakes, low productivity, undependable, lower work quality Absenteeism/Tardiness * 1 = little or no problem2 = troublesome3 = somewhat severe4 = moderately severe5 = extremely severe unauthorized leave, excessive sick leave, frequent absences, lateness, early departures Initiative * 1 = little or no problem2 = troublesome3 = somewhat severe4 = moderately severe5 = extremely severe needs constant supervision, unwilling to make changes, loss of interest, etc. Interpersonal * 1 = little or no problem2 = troublesome3 = somewhat severe4 = moderately severe5 = extremely severe overly critical, customer complaints, false statements, complains to coworkers, etc. Disruptive Behavior * 1 = little or no problem2 = troublesome3 = somewhat severe4 = moderately severe5 = extremely severe bizarre/abnormal actions, making threats of violence, displaying weapons, etc. Appearance * 1 = little or no problem2 = troublesome3 = somewhat severe4 = moderately severe5 = extremely severe unkempt/unclean, disheveled/messy appearance, etc. Attitude * 1 = little or no problem2 = troublesome3 = somewhat severe4 = moderately severe5 = extremely severe towards supervisor, coworkers and patients; unusually sensitive to constructive criticism/advice, etc. Safety * 1 = little or no problem2 = troublesome3 = somewhat severe4 = moderately severe5 = extremely severe disregard for safety of patients, coworkers, supervisors, etc. Personal Problems * 1 = little or no problem2 = troublesome3 = somewhat severe4 = moderately severe5 = extremely severe interfering with work, concern for employee, mood swings, etc. Length of time issue has existed Verbal or written warnings issued Comments Are you requesting the EAP assessment to include the appropriateness of a facilitated conversation with another employee? * Yes No NOTE: Information on this form will be discussed with the client during EAP Assessment. Captcha Submit If you are human, leave this field blank.
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