Supervisor Referral Report Form 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 * 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 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 Is this a mediation case between two employees? * Yes No NOTE: Information on this form will be discussed with the client during EAP Assessment. Submit If you are human, leave this field blank.
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