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    Supervisor Referral Form: Employee Assistance Program

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    Sandra Marquez
    Eduardo Morales Rivera is being referred by his supervisor Steven Anderson to the Employee Assistance Program due to job performance and substance abuse problems. Specifically, Eduardo has shown decreased productivity, increased errors, erratic work patterns, excessive absences over the past 3 months, and failed a random drug test. He also displays frequent mood swings, avoids coworkers, and is unusually sensitive to feedback. The supervisor hopes the EAP can help Eduardo improve his performance and address the underlying issues within the next month to avoid further consequences.

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    Supervisor Referral Form: Employee Assistance Program

    Uploaded by

    Sandra Marquez
    45 views2 pages
    Eduardo Morales Rivera is being referred by his supervisor Steven Anderson to the Employee Assistance Program due to job performance and substance abuse problems. Specifically, Eduardo has shown decreased productivity, increased errors, erratic work patterns, excessive absences over the past 3 months, and failed a random drug test. He also displays frequent mood swings, avoids coworkers, and is unusually sensitive to feedback. The supervisor hopes the EAP can help Eduardo improve his performance and address the underlying issues within the next month to avoid further consequences.

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    Eduardo Morales Rivera is being referred by his supervisor Steven Anderson to the Employee Assistance Program due to job performance and substance abuse problems. Specifically, Eduardo has shown decreased productivity, increased errors, erratic work patterns, excessive absences over the past 3 months, and failed a random drug test. He also displays frequent mood swings, avoids coworkers, and is unusually sensitive to feedback. The supervisor hopes the EAP can help Eduardo improve his performance and address the underlying issues within the next month to avoid further consequences.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    45 views2 pages

    Supervisor Referral Form: Employee Assistance Program

    Uploaded by

    Sandra Marquez
    Eduardo Morales Rivera is being referred by his supervisor Steven Anderson to the Employee Assistance Program due to job performance and substance abuse problems. Specifically, Eduardo has shown decreased productivity, increased errors, erratic work patterns, excessive absences over the past 3 months, and failed a random drug test. He also displays frequent mood swings, avoids coworkers, and is unusually sensitive to feedback. The supervisor hopes the EAP can help Eduardo improve his performance and address the underlying issues within the next month to avoid further consequences.

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    © All Rights Reserved
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    of 2

    SUPERVISOR REFERRAL FORM

    For Mandatory Referrals To The

    EMPLOYEE ASSISTANCE PROGRAM

    Note to the Supervisor: If this is your first time to make a mandatory referral to the Employee
    Assistance Program, please call 806-743-1327 (or 800-327-0328) and ask to speak to the EAP Director.
    Thank you.

    SUPERVISOR AND EMPLOYEE INFORMATION


    Please print
    Eduardo Morales Rivera
    Employees Name: __________________________________

    Referral Date: 22/05/2015


    ______________

    Employer: ______________________________________________________________________
    Procter & Gamble Company
    (787)678-0621
    Department (if applicable): __________________________
    Employees Phone: ______________
    Production

    Production Supervisor
    Referring Supervisors Name: ______________________________
    Title: ___________________
    Steven Anderson
    x No
    Supervisors Phone (work /cell): _____________________ Confidential Voice Mail? Yes

    Supervisors E-Mail (optional): _______________________________________


    [email protected]

    REASON FOR REFERRAL


    Please indicate the reason(s) for this referral (check all boxes that apply).
    x JOB PERFORMANCE PROBLEMS
    x Lower quality of work
    x Decreased productivity

    x Increased errors

    Erratic work patterns


    Failure to meet schedules
    x SUBSTANCE ABUSE PROBLEMS

    Attendance
    Excessive tardiness
    12
    Days late in past month: ____
    x
    Excessive absence
    Days absent past 3 months: _____
    20
    Other __________________

    x Failed random drug or alcohol test. (Please circle which one.)


    Is the employee in a safety sensitive position? x Yes No
    x Post-accident failed drug or alcohol test

    Under the influence at work


    Meets criteria for reasonable suspicion
    BEHAVIORAL CONCERNS
    Disregard for safety

    x Frequent mood swings (high or low)


    Loss of interest
    Impaired judgment/memory
    Inability to concentrate

    x Avoids supervisor/coworkers

    Less communicative
    x Unusually sensitive to feedback
    x Unusually critical of others

    x Conflict with co-workers

    - continued Supervisor Referral

    x VIOLENCE ISSUES
    x Threatened/intimidated others at work (may require Threat Assessment Meeting)
    x Domestic violence

    Harassment

    Please attach additional comments and/or supporting documentation


    for any of the above concerns.

    SUPERVISOR PERFORMANCE GOALS


    1. Have the issues marked on this form been discussed with the employee? x Yes No
    2. What are the consequences if employee performance does not improve?

    3. Have the consequences for not improving been discussed with the employee? Yes No
    4. How will the employees improvement be measured? (Please be specific.)

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

    EMPLOYEE SIGNATURE
    I understand that my supervisor is referring me to the Employee Assistance Program and my
    signature verifies that I have seen this form. My signature below does not signify my agreement or
    disagreement with any of the issues raised.
    x
    Yes, I will participate in and cooperate with the Employee Assistance Program.
    No, I will not participate in the Employee Assistance Program.
    ________________________________________ ________________________
    Signature of employee
    Date

    Please forward this form by mail or fax to:


    Alan Korinek, Ph.D, Director
    Texas Tech University Health Sciences Center
    Department of Psychiatry STOP 8103
    3601 4th Street
    Lubbock, TX 79430-8103
    Phone: 806.743.1327 or 1.800.327.0328
    Fax: 806.743.1323
    Supervisor Referral

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