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Yorkshire Ambulance Service: 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. 

Your details

Address

Nature of referral

Nature of instruction
Has a self assessment and internal DSE been carried out?

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

Please upload your self-assessment and internal DSE assessment here
Maximum 2 files.
8 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

Patient details

Shift pattern
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

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.