Form MS561 "Confidential Eap Supervisory Referral Form" - Maryland

What Is Form MS561?

This is a legal form that was released by the Maryland Department of Budget and Management - a government authority operating within Maryland. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2017;
  • The latest edition provided by the Maryland Department of Budget and Management;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form MS561 by clicking the link below or browse more documents and templates provided by the Maryland Department of Budget and Management.

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Download Form MS561 "Confidential Eap Supervisory Referral Form" - Maryland

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CONFIDENTIAL
EAP SUPERVISORY REFERRAL FORM
The purpose of this form is to provide information to the Employee Assistance Program (EAP) regarding an employee’s poor work
performance when there is reason to believe that the cause may be due to a personal/medical problem. Additionally, please note that
the EAP vendor will inform the State’s EAP Coordinator of each instance where an employee attends and fails to attend a scheduled
EAP counseling session. THIS FORM AND ALL SUPPORTING DOCUMENTATION MUST BE SUBMITTED TO THE
EAP IN DUPLICATE. IF DOCUMENTATION DOES NOT EXIST, PLEASE PROVIDE A SYNOPSIS EXPLAINING THE
BASIS FOR REFERRAL. DO NOT SUBMIT WITHOUT ONE OR THE OTHER.
(Please print in ink, or type)
REFERRAL DATE: _______________
EMPLOYEE’S NAME: ________________________________
GENDER: ________
(Please circle: Mr./Mrs./Ms.)
ADDRESS: ____________________________________________________________________________
(City/County, State, Zip Code)
HOME PH.: _______________ WK.PH.: _______________ CELL PH.: _______________
CLASSIFICATION: _____________________________________
GRADE: _________ EOD: ______________ DOB: ____________ MARITAL STATUS: ___________________
DEPARTMENT/AGENCY NAME: _______________________________________________________________
WORK ADDRESS: ____________________________________________________________________________
(City/County, State, Zip Code)
WORK HOURS/SHIFT: ___________________________ DAYS OFF: _________________
(Please use non-military time)
REFERRED BY: ___________________________ TITLE: ___________________________
PHONE: _________________________________ FAX: ____________________________
AGENCY EAP REPRESENTATIVE: ______________________________ PH._______________
TITLE: ___________________________________
FAX: _________________________
_____________________________________
(Agency EAP Representative’s Signature)
MAILING ADDRESS: _________________________________________
_________________________________________
_________________________________________
REASON FOR REFERRAL
First, check off which type of referral this is. Next, check off the corresponding areas that are relevant to this referral; then
attach documentation or synopsis supporting areas checked and overall reason for this referral. This is a:
I.
SUBSTANCE ABUSE REFERRAL
VIOLATION OF GOVERNOR’S EXECUTIVE ORDER REGARDING SUBSTANCE ABUSE:
______
________
Failed random drug test
Alcohol related conviction
______
Other_______________________________________________________________________
II.
MENTAL HEALTH REFERRAL
ATTENDANCE
:
(Please place numbers where numbers are requested)
______ Number of days absent past 12 mos.
_____ Number of extended lunches
past 6 mos.
______ Pattern (e.g., Mondays, Fridays, after paydays,
_____ Number of times late past 6 mos.
before and after holidays)
_____ Other________________________
________________________
MS 561 (Revised 1/2017)
1
CONFIDENTIAL
EAP SUPERVISORY REFERRAL FORM
The purpose of this form is to provide information to the Employee Assistance Program (EAP) regarding an employee’s poor work
performance when there is reason to believe that the cause may be due to a personal/medical problem. Additionally, please note that
the EAP vendor will inform the State’s EAP Coordinator of each instance where an employee attends and fails to attend a scheduled
EAP counseling session. THIS FORM AND ALL SUPPORTING DOCUMENTATION MUST BE SUBMITTED TO THE
EAP IN DUPLICATE. IF DOCUMENTATION DOES NOT EXIST, PLEASE PROVIDE A SYNOPSIS EXPLAINING THE
BASIS FOR REFERRAL. DO NOT SUBMIT WITHOUT ONE OR THE OTHER.
(Please print in ink, or type)
REFERRAL DATE: _______________
EMPLOYEE’S NAME: ________________________________
GENDER: ________
(Please circle: Mr./Mrs./Ms.)
ADDRESS: ____________________________________________________________________________
(City/County, State, Zip Code)
HOME PH.: _______________ WK.PH.: _______________ CELL PH.: _______________
CLASSIFICATION: _____________________________________
GRADE: _________ EOD: ______________ DOB: ____________ MARITAL STATUS: ___________________
DEPARTMENT/AGENCY NAME: _______________________________________________________________
WORK ADDRESS: ____________________________________________________________________________
(City/County, State, Zip Code)
WORK HOURS/SHIFT: ___________________________ DAYS OFF: _________________
(Please use non-military time)
REFERRED BY: ___________________________ TITLE: ___________________________
PHONE: _________________________________ FAX: ____________________________
AGENCY EAP REPRESENTATIVE: ______________________________ PH._______________
TITLE: ___________________________________
FAX: _________________________
_____________________________________
(Agency EAP Representative’s Signature)
MAILING ADDRESS: _________________________________________
_________________________________________
_________________________________________
REASON FOR REFERRAL
First, check off which type of referral this is. Next, check off the corresponding areas that are relevant to this referral; then
attach documentation or synopsis supporting areas checked and overall reason for this referral. This is a:
I.
SUBSTANCE ABUSE REFERRAL
VIOLATION OF GOVERNOR’S EXECUTIVE ORDER REGARDING SUBSTANCE ABUSE:
______
________
Failed random drug test
Alcohol related conviction
______
Other_______________________________________________________________________
II.
MENTAL HEALTH REFERRAL
ATTENDANCE
:
(Please place numbers where numbers are requested)
______ Number of days absent past 12 mos.
_____ Number of extended lunches
past 6 mos.
______ Pattern (e.g., Mondays, Fridays, after paydays,
_____ Number of times late past 6 mos.
before and after holidays)
_____ Other________________________
________________________
MS 561 (Revised 1/2017)
1
CONFIDENTIAL
JOB PERFORMANCE:
:
(This area must be impacted for referral eligibility, with supporting documentation attached for items checked)
________Lower quality of work
________Failure to meet schedules
________Decreased productivity
________Inability to concentrate
________Increased errors
________Other ____________________________________
________Impaired judgment/memory
____________________________________
________Erratic work patterns
____________________________________
____________________________________
BEHAVIOR DEMONSTRATED WITH RESPECT TO JOB PERFORMANCE:
________Avoids supervisors/coworkers
________Disregard for safety
________Less communicative
________Other_______________________
________Unusually sensitive to advice/constructive criticism
_______________________
________Unusually critical of supervisor/coworkers/employer
_______________________
________Loss of interest
_______________________
________Frequent mood swings
_______________________
DOMESTIC VIOLENCE: _____
Have the above issues been discussed with employee? (Yes) ____ (No) ____
Has employee been referred to State Medical Director? (Yes) ____ (No) ____
If yes, when? (Please attach relevant documents) ____________________________________
IF EMPLOYEE INTENDS TO PARTICIPATE, THIS REFERRAL CANNOT BE PROCESSED WITHOUT “YES”
INDICATED BELOW AND EMPLOYEE’S SIGNATURE
I understand that my employer is referring me to the State Employee Assistance Program. I also understand that my signature below
does not reflect my agreement or disagreement with any of the issues raised. My signature verifies that I have seen this referral and
all documentation contained therein and that I consent to and authorize the EAP vendor to release my attendance or lack thereof to
the State. I understand this consent becomes effective on the date I sign it, and will continue in effect for the duration of the contract
term between the State Employee Assistance Program and EAP Vendor. I agree to release the above named individual(s) or
organization(s) and the EAP, the EAP counselor, and his/her designee from liability that may result from furnishing this information
as authorized in this disclosure.
_______ YES, I will participate in the Employee Assistance Program. My health insurance carrier is:
______________________________________________
________ NO, I will not participate in the Employee Assistance program.
______________________________________________
____________________________________
Signature
Date
Your agency EAP Representative should forward this form and all supporting documentation IN DUPLICATE to:
Maryland Department of Budget and Management
Employee Relations Division
Employee Assistance Program
301 W. Preston Street, Room 607
Baltimore, Maryland 21201
or Fax to: 410-333-7603
If you have questions, please contact the Employee Assistance Program at 410-767-5846.
FAILURE TO LEGIBLY AND FULLY COMPLETE THIS FORM WILL RESULT IN APPOINTMENT DELAY
Providing your social security number will help us verify your identity. If you do not provide this information, your referral will still be
processed. Your SSN will be kept confidential in accordance with federal and State laws and regulations and the Maryland Public
Information Act (SG 10-624c).
MS 561 (Revised 1/2017)
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