Supervisor Referral Report Form Supervisor Referral Report Supervisor Referral Report Date of Referral Report * Employee Information Employee's Name * 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 Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Supervisor Information Supervisor's Name * Supervisor's Job Title * Supervisor's Phone * Supervisor's Email * HR Business Partner * 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 problem 2 = troublesome 3 = somewhat severe 4 = moderately severe 5 = extremely severe missed deadlines, frequent mistakes, low productivity, undependable, lower work quality Absenteeism/Tardiness * 1 = little or no problem 2 = troublesome 3 = somewhat severe 4 = moderately severe 5 = extremely severe unauthorized leave, excessive sick leave, frequent absences, lateness, early departures Initiative * 1 = little or no problem 2 = troublesome 3 = somewhat severe 4 = moderately severe 5 = extremely severe needs constant supervision, unwilling to make changes, loss of interest, etc. Interpersonal * 1 = little or no problem 2 = troublesome 3 = somewhat severe 4 = moderately severe 5 = extremely severe overly critical, customer complaints, false statements, complains to coworkers, etc. Safety * 1 = little or no problem 2 = troublesome 3 = somewhat severe 4 = moderately severe 5 = extremely severe disregard for safety of patients, coworkers, supervisors, etc. Length of time issue has existed Verbal or written warnings issued Is this a mediation case between two employees? * Yes No NOTE: Information on this form will be discussed with the client during EAP Assessment. reCAPTCHA If you are human, leave this field blank. Submit