Referral Form - ergonomic worksite assessment

Referring employer name *

First Name

Last Name

Consent - Has the employee consented to the referral and issue of consent form? *

N.B. Ergability will issue consent form directly to referred individual upon receipt of completed online referral form.

Yes

No

Employee's name *

First Name

Last Name

Goals for assessment (information required) *

Fitness for work recommendation

Additional information on nature of health condition/s and prognosis

Recommended workplace adjustments and / or return to work plan

Recommendations to address any identified occupational health related issues / barriers

Employee's current work status *

At work on full duties / hours

At work on modified duties and / or hours

Off work

Does the employee have a current fit note? *

Yes

No

Does the employee regularly work night shift (working between 10pm and 4am)? *

Yes

No

Details of job demands *

Please check the relevant boxed below for specific demands that are required as part of the employee's job role

Lifting - floor to waist

Lifting - waist to shoulder

Lifting - above shoulder

Carrying

Pushing / pulling with significant force

Sitting

Standing

Walking

Stair climbing

Ladder climbing

Driving (including car, fork lift, lorry etc)

Working at heights

Working in confined spaces

Kneeling, squatting and / or spinal bending

Working in hot / cold conditions

Working with vibrating tools and / or machinery

Working to fixed time constraints

High workload demands

Critical thinking and problem solving

Managing people

Please advise if your company provides any of the following health and / or wellbeing services

Employee Assistance Programme (EAP)

Physiotherapy

Counselling and / or psychological support