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

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

CUSTOMER INFORMATION

Date of Referral:

Name of Referrer:

Company:

Job Title:

Email Address:

Phone Number:

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) 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:

RETURN TO WORK/ EMPLOYEE ACCOMMODATION

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

Special Instructions or Background Info:

EMPLOYEE INFORMATION (If employee-specific service)

Employee Name:

Employee Email:

Employee Phone:

Worksite Address :

Special Instructions:

REPORT AND INVOICING

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: