Kaelo Lifestyle Formal Referral

The Kaleo Lifestyle formal referral is a tool used by managers where there are documented work challenges related to the performance and or conduct of an employee.
In order for the Kaleo Lifestyle Programme team to facilitate the process, we require as much information as possible, to give us insight into the challenges at hand. Please complete the document in as much detail as possible.

The employee is required to sign the consent form in order for the Kaelo Lifestyle Programme team to provide the referring manager with progress feedback. Where an employee does not sign the consent form, no feedback shall be provided. The formal referral is a voluntary process and employees cannot be forced to sign the consent form.

Your Kaelo Lifestyle Plan *

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Important Information

Company *

Employee's Full Name *

Preferred Time to Contact the Employee

Morning

Afternoon

Referring Manager's Full Name *

Preferred Time to Contact the Referring Manager

Morning

Afternoon

Details of Employee Being Referred

Full Name *

ID No. / Date of Birth *

Position *

Division / Region / Business Unit *

Cell Number *

Work Number *

Email Address *

Next of Kin Name *

Contact Number *

Details of the Referring Manager

Full Name *

ID No. / Date of Birth *

Position *

Division / Region / Business Unit *

Cell Number *

Work Number *

Email Address *

HR Manager (if applicable)

Full Name

Cell Number

Work Number

Email Address

Details of the Referral

What is the reason for this formal referral? *

Please use the list below to indicate the impact of these challenges. If none of the below is applicable, this is probably not a formal referral.

Absenteeism and Attendance

Excessive sick leave

Sick leave trend on Mondays, Fridays, before or after public holidays

Taking leave without permission

Regular need to leave work early

Vague explanation for absence

Frequently away from workstation

Arriving late for work

Taking long lunch breaks

Sleeping on duty

Job Performance Problems

Lower quality of work

Decreased productivity

Increased errors

Missing deadlines

Substance Abuse Problems

Failed random drug or alcohol test

Under the influence at work

Meets criteria for reasonable suspicion

Violence Issues

Threatened / intimidated others at work

Domestic violence

Harassment

Does this referral form part of any disciplinary process? *

Yes

No

Has the issue highlighted in this form been discussed with the employee? *

Yes

No

What are the consequences if the employee's performance does not improve? *

Have the consequences for not improving been discussed with the employee? *

Yes

No

How will the employee's improvement be measured (be specific)? *

How long will the employee be given to make the desired changes? *

Consent

I hereby grant consent to being referred to the Kaelo Lifestyle Programme. I give consent for my referring manager to receive a report at the end of the intervention regarding my attendance and the progress that was made during the formal referral process. I acknowledge that the personal information I discuss with the counsellor will not be disclosed or detailed in the report and my confidentiality will be protected.

Employee's Signature

Clear

Referring Manager's Signature

Clear