Thank you for your referral to Fit To Work, Inc. Please fill out the information below:
Client Information
Referral Source Information
Address:
Agency:
Telephone:
Mailing Address:
email:
Your Telephone:
Injury/Disability:
Agency Fax:
Claim #:
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Basic Ergonomic/Assistive Technology Analysis and Report: This service includes interview and observation to determine the individual’s functional limitations, recommendations for ergonomic devices or other assistive technology. This does not include purchase or installation of the suggested solutions.
Comprehensive Ergonomic/Assistive Technology Analysis, Report and Plan
Implementation: This service includes the initial ergonomic analysis, may include trial use of equipment to determine effectiveness of the strategies, client instruction, assistance in equipment purchasing, installation and follow-up. This process may require 2-3 visits.
Functional Screening Evaluation: Testing is conducted to develop a profile
of the individual’s physical abilities and limitations and to determine whether their physical abilities fit current vocational goals. This includes a half day of testing and development of a final report.
Physical Demands Job Analysis: To determine the physical requirements of a
specific job. Includes travel, interview, photographs, specific measures.
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