Kaelo Lifestyle Formal Referral 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 * Kaelo Lifestyle | AskNelson Kaelo Lifestyle | Africa Kaelo Lifestyle | Digital 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 Behavioural Concerns Avoids supervisor / coworkers Less communicative Unusually sensitive to feedback Unusually critical of others Conflict with coworkers Disregard for safety Frequent mood swings Loss of interest Impaired judgement / memory Inability to concentrate 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 If you are human, leave this field blank. Submit
