Page 150 - Personnel Policy and Procedures Manual

CONCERN: EAP SUPERVISORY REFERRAL FORM CONT.

Complaints of not feeling well:
Undependable statements:

Deteriorating appearance:

Outside forces (i.e., family and financial garnishments) beginning to interfere with work:
Hospitalized more than should be expected:

Changes in personality pattern:

The above listing is intended only as a guide. These indicators are most reliably applied to employees who
have been good performers in the past but who have had a recent decline in job performance.

Additional Information:
(Please list any additional information or comments, which you feel, could be helpful. Attach additional
sheets if necessary.)

RELEASE OF INFORMATION: (To be reviewed and signed during interview)

I authorize CONCERN: EAP to advise the person listed below whether or not I scheduled and/or kept an
appointment for services.

EMPLOYEE: DATE:

Title:
Supervisor

Telephone Date:

CONTACT PERSON: TELEPHONE: (If different from above)

FORM SA-5 Page 2 of 2

All Rights Reserved – As approved by the Commission on 05-07-2019 150 | P a g e