Supervisor Referral Report Form – Faculty Physicians Inc.

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

City

State/Province

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 *

missed deadlines, frequent mistakes, low productivity, undependable, lower work quality

Absenteeism/Tardiness *

unauthorized leave, excessive sick leave, frequent absences, lateness, early departures

Initiative *

needs constant supervision, unwilling to make changes, loss of interest, etc.

Interpersonal *

overly critical, customer complaints, false statements, complains to coworkers, etc.

Safety *

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.

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