Template for an employer to get information about a worker's health when it's relevant to their job. Free to use.
You must get permission from the worker before contacting their doctor.
Find out more about getting a doctor's report about a worker's health
You can copy and paste the template text into an email or document.
Template
To: [doctor's name]
[Doctor's address]
From: [your name]
[Name of your organisation]
[Address of your organisation]
[Today's date]
Dear [doctor's name]
I am writing for information about your patient [name of worker], who lives at [address of worker].
I am [a / an] [your role] at [name of your organisation]. Your patient works as [a / an] [worker's job title] at the organisation.
I have attached the worker's permission for me to make this request. They [want / do not want] to see the report before you send it to me.
I would like information in order to [manage sick pay / plan work / support the worker].
I would like information about:
[List the things you're asking about. For example:
- their absence from work, including absence dates
- their health condition, such as a broken wrist]
Their role involves:
[List any worker tasks or responsibilities the condition might affect. For example:
- standing for long periods
- heavy lifting
- working evenings
- using a keyboard
- driving]
I would like to know:
[List any other information you need. For example:
- the condition's impact on carrying out their tasks or responsibilities
- whether the worker is disabled
- reasonable adjustments that might be needed
- a likely date the worker will return to work
- if a phased return to work, change of duties or other support might help the worker]
Let me know if I need to pay a fee for this information.
If you're unable to provide the requested information quickly, please reply to confirm you've received this.
Please reply [by email / by post − a stamped addressed envelope is enclosed].
Yours sincerely,
[Your name]
[Your telephone number]
[Your email address]
Download this template
- Download this template in Microsoft Word format (DOCX, 16KB)
- Download this template in Open Document format (ODT, 9KB)
If you need the template in a different format, email digital@acas.org.uk