Yorkshire Ambulance Service: Management ergonomic assessment referral

The following form is for managers looking to refer a member of staff for an ergonomic assessment as part of the Occupational Health Physiotherapy Service for employees of the Yorkshire Ambulance Service.

Once we have received the referral, a therapist will be in contact to arrange a time to complete the assessment.

Manager details

First name

Surname

Name of file handler (if applicable)

Address

City/Town

Postcode

File reference number

Direct dial telephone number

Email address

Date of referral

Nature of referral

Desk based assessment

Non-desk based ergonomic assessment

Any further specific instructions:

Has an enhanced DSE self assessment and YAS DSE Assessor Review been carried out?

Yes

No (If no, please do not proceed with referral. YAS must complete enhanced DSE assessment before referring on to Ascenti).

We will not be able to accept a referral until this has been carried out.

Please upload your completed DSE Workstation assessment form here

Patient details

Title of patient e.g. Mrs / Miss / Ms

Name

Address

Postcode

Date of birth

Home phone number

Work phone number

Mobile

Email address

Job role

Location

	Shift pattern
Monday	Monday
Tuesday	Tuesday
Wednesday	Wednesday
Thursday	Thursday
Friday	Friday
Saturday	Saturday
Sunday	Sunday

Reason for referral

Litigation friend details (if applicable)

Once we have received the referral, a therapist will be in contact to arrange a time to complete the assessment.

If you would like to speak to somebody regarding this referral, please call 0330 678 0850.

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Yorkshire Ambulance Service: Management ergonomic assessment referral

Manager details

Nature of referral

Patient details

Once we have received the referral, a therapist will be in contact to arrange a time to complete the assessment. If you would like to speak to somebody regarding this referral, please call 0330 678 0850.

Once we have received the referral, a therapist will be in contact to arrange a time to complete the assessment.

If you would like to speak to somebody regarding this referral, please call 0330 678 0850.