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Ergonomic and Injury Prevention Referral Form

CUSTOMER INFORMATION

Date of Referral:

Name of Referrer:

Company:

Email Address:

Phone Number:

EMPLOYEE INFORMATION

Employee Name:

Employee Email:

Employee Phone:

Worksite Address :

Employee Ergonomic:

Individual Ergonomic Assessment (employee specific with report) Ergonomic Screenings (multiple assessments with checklist solutions) Virtual Ergonomic Assessment (remote video analysis with report)

Job Assessments:

Job Demands Analysis (physical, cognitive, psychosocial demands) Physical Demands Analysis (physical demands only) Ergonomic Job Analysis (preventative analysis of specific job)

Ergonomic Training:

Creating Effective Injury Prevention Programming Office Ergonomics- 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

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 and Vocational Rehabilitation Specialists are your reliable and responsive service partners who are ready to optimize ergonomics and ability!

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Enabling Access Inc.

PO BOX 272, 971 Corydon Ave

Winnipeg Manitoba Canada

R3M 3S7