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Ergonomic and Injury Prevention Referral Form

CUSTOMER INFORMATION

Date of Referral:

Name of Referrer:

Company:

Job Title:

Email Address:

Phone Number:

EMPLOYEE INFORMATION (If relevant)

Employee Name:

Employee Email:

Employee Phone:

Worksite Address :

ERGONOMICS AND INJURY PRVENTION SERVICES

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) Ergonomics Assessment (person-specific/ job-specific, comprehensive report)

Ergonomic Training:

Office Ergonomics 1-hr Session- Preventing MSI's at Work Office Ergonomics Assessor Training (one day) Industrial Ergonomics Assessor Training (two day) Customized Ergonomic Manual Material Handling *Requires Ergonomic Job Analysis as prerequisite Safe People Lifting and Handling Situational Awareness Safety Minimizing Occupational Vibration Exposure Safety Considerations for the Aging Worker Stretch, Flex and Prevent Sprains & Strains Occupational Vibration Exposure Managing Stress at Work and Home Nutrition and Healthy Living for Shift Workers Successful Disability Mangement- Connecting HR to Safety & Injury Prevention

Special Instructions:

REPORT AND INVOICING

Forward Report to Name:

Forward Report to email:

Forward Invoice to Name:

Forward Invoice to email:

Please call to arrange for Post-offer Pre-employment Testing and to book Independent Medical Examinations

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Enabling Access' team of expert Occupational Therapists are your reliable and responsive service partners who are ready to improve accessibility, optimize ergonomics and ability!

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Enabling Access Inc.

1431Corydon Ave

Winnipeg, Manitoba

Canada

R3N 0J2