Enabling Access : Ergonomics and Injury Prevention Services Referral Forms

Phone: 204-475-0433
Fax: 204-475-4011
Email: info@enablingaccess.ca

Ergonomic and Injury Prevention Referral Form

*indicates required fields.

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 ProgrammingOffice Ergonomics- Preventing MSI's at WorkOffice Ergonomics Assessor Training (one day)Industrial Ergonomics Assessor Training (two day)Customized Ergonomic Manual Material Handling *Requires Ergonomic Job Analysis as prerequisiteSafe People Lifting and HandlingSituational Awareness SafetyMinimizing Occupational Vibration ExposureSafety Considerations for the Aging WorkerStretch, Flex and Prevent Sprains & StrainsOccupational Vibration ExposureManaging Stress at Work and HomeNutrition 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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