Enabling Access Inc. : Disability Management Services Referral Form (Injury Prevention, Stay at Work, Return to Work)

Date of Referral:

Name of Referrer:

Company:

Job Title:

Email Address:

Phone Number:

Office Ergonomics:

Office Ergonomics Assessment (employee-specific, comprehensive report) Office Ergonomics Screenings (multiple employees, with checklist forms) Clinic-based ergoLAB Ergonomics and Assistive Technology Equipment Assessment and Trials

Industrial Ergonomics:

Job Demands Analysis (physical, cognitive, psychosocial demands) Physical Demands Analysis (physical demands only) Cognitive Demands Analysis (Cognitive demands only) Non-office/Industrial Ergonomics Job Evaluation (NOT employee-specific) Functional Capacity Evaluations (1 or 2-day) Cognitive Functional Capacity Evaluation (2-day) Post-offer Employment Testing

Special Intructions or Background Info:

RTW Services:

Return to Work Program Consultation Return to Work Employee-Specific Coordination

Employee Accommodation Services:

Employee Accommodation Program Consultation Employee-specific Workplace Accommodation Assessment

Disability Mangement & Injury Prevention Training:

Special Instructions or Background Info:

Employee Name:

Employee Email:

Employee Phone:

Worksite Address :

Special Instructions:

Forward Report to Name:

Forward Report to email:

Name to Appear on Invoice:

Job Title to Appear on Invoice:

Legal Company Name to Appear on Invoice:

Email Address to send Invoice:

Disability Management Services Referral Form (Ergonomics, Stay at Work and Return to Work)

Fill out a referral form to get started!