A Job Performance Referral is a referral initiated by a supervisor or a manager when work performance or behavior is an issue, for example, poor quality or quantity of work, unacceptable conduct, absenteeism or tardiness, or interpersonal relationship problems with other employees or the public. The checklist that follows has been designed to help you gather information and prepare for your discussion with the EAP Consultant.

General Information

• Supervisor’s Name
• An alternate person to contact
• Work location address
• Name of employee to be referred
• Employee’s address, including county

Statistical Information

• Employee’s length of service
• Age, gender, marital status, social security number
• Position title
• Employee’s health insurance
• Bargaining unit (or wage level) of employee if applicable

Description of Problem

• Performance issues occurring at work:
• Quality of work
• Relationships at work or with the public
• Behavior/conduct
• Absenteeism/tardiness—frequency and patterns
• History of problem—how long?

Progressive Action

• Progressive/corrective action taken or pending which is relevant to current problems
• Future status (i.e. what will be the next step in progressive action if the employee does not improve)

Note: The EAP Consultant will coordinate an assessment and referral session with a counselor as soon as the employee agrees to participate in the Job Performance Referral.