SUPERVISORY REFERRAL TO EAP

1

• SUPERVISORY REFERRAL TO EAP
• Employee Name__________________________
  Date___________
• Employee Job Title_________________
  Department____________
• Referred by______________________
  Title___________________
• REASONS FOR REFERRAL
• Excessive Absenteeism
• (Attach attendance card for past year of show
  pattern, I. e., Monday, Friday absences, etc. for
  past year.)
• Excessive Tardiness, Leaving Early (record
  frequency below)
• Past 6 months_________ Past year_________
  Previous year________
• Unusual Excuses of Absenteeism (specify)
• _________________________________________________
  _________
• _________________________________________________
  _________
• Leaves Workplace Frequently
• Extends Lunch periods, Breaks, Vacations
• Other (specify)
• _________________________________________________
  _________

2

• BEHAVIOR ON THE JOB
• ____ Avoids supervisor/co-workers ____ Unusually
  critical of others
• ____ Disregards safety ____ Does not communicate
• ____ Lacks interest/ enthusiasm ____ Moody
• ____ Unusually sensitive to criticism ____ Other
  (specify)
• __________________________________________________
  _________________
• __________________________________________________
  _________________
• __________________________________________________
  _________________
• PHYSICAL APPEARANCE/GROOMING (Explain)
• __________________________________________________
  ___________
• __________________________________________________
  ___________
• __________________________________________________
  ___________
• ADDITIONAL COMMENTS BY REFERRING SUPERVISOR