Adjustment Passport - Our Tesco

---

Adjustment Passport Your name:

Mandy Smith

Your manager’s name:

Lois Thompson

Date:

9th December 2015

This ‘adjustment passport’ is a live record of adjustments agreed between you and your manager/People Manager/Partner to support you at work because of a health condition or disability. It’s for you to keep and pass onto anyone you think needs to know about your condition and any impact it may have on you (we won’t do this automatically). The purpose of this passport is to:   

make sure that everyone’s clear and has a record on what’s been agreed; reduce the need to re-assess adjustments every time you change jobs, are re-located or are assigned a new manager; provide you and your manager, People Manager/Partner with the basis for future conversations about adjustments

This should be reviewed regularly (at least every six months) or if there is a change to your health condition or disability and amended where appropriate. Remember that your manager may need to get additional advice from Fit for Work, Occupational Health, Access to Work, the People Team etc. before any adjustments or changes can be agreed and implemented. If you change your job or you have a new manager, you should provide a copy of this to them so that they understand what adjustments have been made for you. If you’re in the same role and your health condition remains the same, new managers should accept the adjustments outlined in the Passport. The agreement may need to be reviewed and amended at a later date, but this shouldn’t happen until you’ve both worked together for a reasonable period of time. If your health condition changes, you have moved to a new role, store, site, desk etc., or there are any other changes to your job which mean that the adjustment may no longer be appropriate; then the adjustments may be reviewed straight away. Adjustment Passports aren’t stored or recorded centrally, therefore it’s your responsibility to keep it safe and supply it when necessary. Your manager/People Manager/Partner should also keep a copy for their own records in your personnel file. If a review date is specified in this Adjustment Passport, you should put this in your calendar and let your manager/People Manager/Partner know when the date arrives. But please speak to your manager at any time if you believe your medical needs have changed and it needs to be reviewed earlier. Managers/People Managers/Partners should refer to the Managing Disability Guide for more information and help on making adjustments. Page 1 of 7, Version 1, February 2016

Adjustment Details I believe that my disability/health condition has the following impact on me at work:

I have anxiety and depression (the colleague does not have to tell us what the medical condition is if they don’t want to) At work my health condition impacts me by affecting; My confidence with others My emotional state My memory- I find it harder to remember things that I would normally My communication skills- I find it harder to talk to other people especially people I don’t know very well My involvement with the rest of the team – I find it hard to socialise and would rather be myself

The following adjustments have been agreed between me and my manager:

If I am feeling down I will tell my manager Have regular “how are you doing” informal meetings with my manger every 2 weeks Be moved away from customer focused task when feeling low Adjustments to shift patterns to go for counselling

Has any additional advice been given or requested? If so from whom and what date was it requested/given: (Please attach any such information to the back of this document).

Advice provided on a fit note from GP and information from her support worker re things that could help at work 9th December 2015

Date of implementation:

Page 2 of 7, Version 1, February 2016

My condition at work Please complete if you have a fluctuating mental or physical condition. On a good day I believe that my disability/health condition has the following impact on me at work.

On a good day I am able to complete all aspects of my job role with no support

When things are not so good, the following symptoms are indications that I’m not well.

I may be quiet / and feeling down I may request additional breaks I may be tearful I may ask to go home I may have difficulty communicating I may be angry and short tempered with others

Page 3 of 7, Version 1, February 2016

Emergency Contacts If I’m not well or there are concerns about my wellbeing, I’m happy for my manager or the people manager/partner to contact any of the following emergency contacts in order of preference indicated below. Please add, amend or delete contact types as appropriate or when there are any changes. Relative (preference no. 1 ) Name: Bob Smith Relation to me: Husband

Specialist / Care Co-Ordinator / Support Workers / GP (preference no. 2 ) Name: Jan Brown

Telephone: XXXXXXXXXXX

Relationship to you: Support Worker (e.g. support worker) Telephone: XXXXXXXXXXX

Mobile: XXXXXXXX

Mobile:

Friend (preference no. 3

)

Other (please specify) (preference no.

Name: Jane Johnson

Name:

Telephone: XXXXXXXXXXXX

Telephone:

Mobile: XXXXXXXXX

Relationship to you (e.g. GP):

)

I agree that I will let you know if there are changes to my condition which have an effect on my work and/or if the agreed adjustments aren’t working. We will then meet to discuss any further adjustments or changes that should be made. If you notice a change in my performance at work or feel these adjustments aren’t working I am happy to discuss what needs to be done. I agree to hold an up to date copy of this Passport and supply it as and when requested to. I also agree that a copy of this form may be given to a new or prospective manager, but that it is my responsibility to ensure that any new manager, or anyone I think would need to know about my condition and the adjustments, are informed about the Adjustment Passport by me. Your signature:

Date:

Manager’s signature:

Date:

Page 4 of 7, Version 1, February 2016

Adjustment review record 9th Feb 2016 Date of review: I believe there are no changes to my disability/ health condition and that the agreed adjustments should remain in place as detailed above:

(to be signed by the colleague)

I believe there have been the following changes in my disability/health condition which require the following changes to be made to my current agreed adjustments:

My condition got worse over Christmas I find this time of year very difficult my Dr wonders if I may have SAD and has recommended some light therapy and additional counselling support My absence is now over the support level and this is increasing my anxiety I am not sure what other help you can give I am aware that I let the team down

Please detail adjustments agreed

Agreed following discussion with People Manager that we will with Mandy will contact Remploy to see if they will come into the work place and undertake a review of the support we have offered and if there is anything else we can do help you. 2 weekly meetings to continue Mandy to tell manager is she is feeling unwell Tasks for the day to be agreed and written down for Mandy to Follow Speak to FFW support line for some additional advice and support re Mandy’s health issues Sign posted Mandy to EAP for any additional support i.e. financial help if required

Your signature:

Mandy Smith

Date:

9th Feb 2016

Manager’s signature:

Lois Thompson

Date:

9th Feb 2016

Date of next review:

9 March 2016

Page 5 of 7, Version 1, February 2016

Adjustment review record (cont. sheet) 7th May 2016 Date of review: (to be signed by the colleague) I believe there are no changes to my disability/ health condition Mandy Smith and that the agreed adjustments should remain in place as detailed above: I believe there have been the following changes in my disability/health condition which require the following changes to be made to my current agreed adjustments:

My anxiety has worsened again and my Dr has changed my medication and I am struggling with all aspects of life including attending work

Please detail adjustments agreed

Following Remploy’s visit to store last week they are supporting Mandy with a case worker 2 days a week at work for 4 hours starting next week We have agreed with Mandy today to move her to produce and buddy her with Team Leader Tom so that she is not working alone We will amend her shifts as agreed with Mandy temporarily so they can work together If this fails and Mandy is still struggling to attend work we have agreed we would ask for advice from Occupational Health

th

Your signature:

Mandy Smith

Date:

9 March 2016

Manager’s signature:

Lois Thompson

Date:

9 March 2016

Date of next review:

9 April 2016

Page 6 of 7, Version 1, February 2016

th

Page 7 of 7, Version 1, February 2016