Model letters of referrals for downloading
Letters of referral to prophylactic as well as sanitary and epidemiological examinations
The Occupational Medicine specialist performs the examination on the basis of the original letter of referral issued by the employer. This document is kept in the patient’s medical documentation, containing information on hazards and harmful factors existing at the workstation.
The correctly completed letter of referral should:
- be exact and legible
- contain all indispensable data and information on the workstation
- bear all required stamps (the company’s stamp including the REGON number) and the signature of the person authorised to issue the letter of referral (OSH officer or a person that is familiar with the working environment, e.g. the manager of the specific department)
- be completed in Polish, including the job title.
When coming to the examination, the employee should have the letter of referral valid for three months of the date it was issued.
The letter of referral to an Occupational Medicine examination is an official document, and therefore it is important that the information contained in it is up-to-date. The employer is responsible for the contents of this document.
The letter of referral may be an important document in litigation, e.g. if the employee develops an occupational disorder.
Occupational Medicine specialists are under a legal obligation to include the following in the medical records:
- identification data of the patient’s workplace (name, address and REGON identification number),
- the employee’s NIP (Taxpayer Identification Number).
Legal basis:
Journal of Laws No. 69 of 25 June 1996 item 332,
Journal of Laws No. 37 of 4 March 2003 item 328.