Supervisor Referral Report

Employee Information

Employee's Address *
Employee's Address

Supervisor Information

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

missed deadlines, frequent mistakes, low productivity, undependable, lower work quality
unauthorized leave, excessive sick leave, frequent absences, lateness, early departures
needs constant supervision, unwilling to make changes, loss of interest, etc.
overly critical, customer complaints, false statements, complains to coworkers, etc.
bizarre/abnormal actions, making threats of violence, displaying weapons, etc.
unkempt/unclean, disheveled/messy appearance, etc.
towards supervisor, coworkers and patients; unusually sensitive to constructive criticism/advice, etc.
disregard for safety of patients, coworkers, supervisors, etc.
interfering with work, concern for employee, mood swings, etc.
Is this a mediation case between two employees? *
NOTE: Information on this form will be discussed with the client during EAP Assessment.