Enabling Access Inc. : Workplace Health and Inclusion Request for Service Form (Injury Prevention, Stay at Work, Return to Work)

Name :

Job Title:

Company:

Email :

Phone :

Ergonomics :

Office Ergonomics Assessment - employee specific Office Ergonomics Screenings - multiple employees ergoLAB Ergonomics and Assistive Technology Equipment Trials Industrial Ergonomics Assessment - employee specific Industrial Ergonomics Task Analysis - job specific Ergonomics Worksite Design

Job Demands:

Physical Demands Analysis Cognitive Demands Analysis Job Demands Analysis - physical, cognitive, psychosocial demands

Abilities Testing:

Functional Capacity Evaluations (1 or 2-day) Cognitive Functional Capacity Evaluation (2-day) Post-offer Employment Testing

Psychological Heatlh and Safety:

Psychological Health and Safety in the Workplace Audit

Employee Accomoodation:

Employee Accommodation Assessment

Accessibility:

Environmental/Physical Accessibility Audit -Full Site or Specific Spaces Customer Service Accessibility Audit Accessible Event Audit Accessible Employment Audit

Special Intructions or Background Info:

Return to Work :

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

Workplace Health and Inclusion 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:

Bill to Address:

Bill to Postal Code:

Email Address to send Invoice:

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Workplace Health and Inclusion Request for Service Form

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