Adjustment Passport - Our Tesco


Feb 7, 2016 - ...

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Adjustment Passport Your name:

Mandy Smith

Your manager’s name:

Lois Thompson

Date:

9th August 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 6, Version 1, February 2016

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

I have Rheumatoid Arthritis that affects my hands, arms feet and knees (the colleague does not have to tell us what the medical condition is if they don’t want to) At work it impacts my ability to: Move heavy objects Sit or stand for too long Bend to the floor or down low

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

To work in Health and Beauty as this is a less physical area of replenishment Cages are pulled out to the shop floor for me I use a flatbed trolley to fill the shelves from If I am in a lot of pain my colleagues support me with filling the lower shelves Time off to attend hospital appointments

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).

None at present

10th August 2015 Date of implementation:

Page 2 of 6, 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 may have to work a bit slower than some other colleagues but I am able to complete all aspects of my job.

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

My movements are limited My Joints are swollen I may be quiet / and feeling down I may request additional breaks I may be tearful I may have to ask for help from some of my colleagues

Page 3 of 6, 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. ) Name:

Telephone: XXXXXXXXXXX

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

Mobile: XXXXXXXX

Mobile:

Friend (preference no. 2

)

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 6, Version 1, February 2016

Adjustment review record 7th 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 has flared up due to the cold weather / my feet and knees much worse and my consultant says I need a knee replacement I would like reduce my hours by 3 hours on each of my 2 full 8 hour shifts as this too painful for me to be on my feet for this length of time This would reduce my hours to 4 days @ 5 hours

Please detail adjustments agreed

Agreed following discussion with People Manager that this support can be implemented Reduced contracted will start w/c 16.02.16 Speak to FFW support line for some additional advice and support re Mandy’s health issues and how we can help her Sign posted Mandy to EAP for any additional support i.e. financial help if required

Your signature:

Mandy Smith

Date:

7th Feb 2016

Manager’s signature:

Lois Thompson

Date:

7th Feb 2016

Date of next review:

7 May 2016

Page 5 of 6, 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:

No changes are needed but I am still waiting for a date for my new knee.

Please detail adjustments agreed

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Your signature:

Mandy Smith

Date:

7 May 2016

Manager’s signature:

Lois Thompson

Date:

7 May 2016

Date of next review:

Page 6 of 6, Version 1, February 2016

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