Physician Service Request

For an Ergonomic Worksite Analysis (EWA)

Physician Service Request

When employees experience a work-related musculoskeletal injury (WMSD), an ergonomic assessment identifies the root cause of their injury claim. Our expert workers' compensation physicians determine more accurate work restrictions, physical capacities required of the job and return to work strategies resulting in a successful return to productive work. Physicians concur with our findings and recommendations 100% of the time.

Steps to refer an employee for an Ergonomic Worksite Analysis (EWA)

  1. Complete the form and submit the form. If you prefer our PDF form, click here. 
  2. Complete the Request for Authorization (RFA) and submit to the insurance adjuster
  3. We will contact you within 24 hours once we receive your referral to set up your site visit date with the employee and supervisor.

Once our ergonomic analysis is complete, we will forward the report to all individuals checked on this form. Our reports typically take 7‐10 work days unless you request it as a “rush.” For questions or additional support, please contact us.

Service Descriptions

Medical Only (MO)WC Ergonomic Worksite Analysis (Level II)

Our Medical Only (MO) WC ergonomic Worksite analysis is designed to keep injured workers at work by identifying the root cause or biomechanical actions contributing to their (musculoskeletal) discomfort/injury. We analyze the typical work routine and instruct the employee in safe work practices, self‐care and stretching. Quick fixes and discussion of alternative ways of working and tool use is provided. A thorough report of all findings, actions taken and recommendations including appropriate ergonomic products, facility actions, IT changes and administrative actions are provided. The physician reviews and concurs with this report to make it prescriptive for implementation by the insurer and employer. On-site time: 60‐90 minutes.

Indemnity WC (Lost Time/Complex; Ergonomic Worksite Analysis for Return to Work (Level III)

Our Indemnity WC ergonomic analysis is appropriate for complex, lost time claims where the injured worker has undergone surgery and/or has been out of work for an extended period of time due to the injury. A Functional Limitations Report conducted with the injured employee provides details on the tasks and activities they feel they can/cannot do relative to their injury status. It is used in conjunction with a detailed analysis of the ergonomics and functional issues required of the job. The foundations described in the MO EWA are utilized including recommendations to facilitate a successful RTW plan. This report assists the physician, employer and insurer in determining appropriate modified and transitional work for a successful outcome. Physician concurs with findings to make recommendations part of the treatment plan. Requires employee be released to RTW for assessment. On-site time: 1.5‐2 hours

ADA Reasonable Accomodation (RA) Assessment (Interactive Process

Our ADA RA Assessment is fully compliant with FEHA/ADA and the EEOC’s criteria in performing the interactive process with your employee when a reasonable accommodation is needed. Whether it is for a permanent workers’ compensation injury or other medical condition or disability, this service is the best option to identify the most appropriate reasonable accommodations for a successful RTW. We work with all parties involved in the case to identify the solutions that support accommodation. We utilize our functional limitations report, ergonomic analysis, job analysis and functional job matching assessment tools to create the ADA RA Assessment report. Our legally defensible process minimizes litigation and costs for the employer while assuring a successful outcome. On-site time: 2‐3 hours

Job Analysis and Physical Demands

Our Job Analysis is an investigative tool that involves interviewing and observing an individual (injured worker) and/or co‐workers actually perform the job. We document the essential functions, evaluate to what extent and how the work is done focusing on time and effort required. We assess the physical, sensory and cognitive/mental demands of the job, tools and materials handled in the environment performed. We document objectively using time allocation units and force/repetition requirements so that the employer, physician and insurer can determine whether the employee is fit to return to work or requires accommodation. This document assists with creating appropriate modified duty and transitioning the injured worker back to full duty. On-site time: 2‐3 hours per job analysis

Job Matching (Gap Analysis to match job function to ability)

This on-site function‐ matching service combines ergonomic analysis, job analysis and physical demands with on-site testing of an employee’s abilities and limitations to match them to their current job’s essential functions. Various tasks from the job that require exertion are objectively tested to determine whether employee passes or the task needs modification. Our analysis and report takes the guess work out of whether the employee can perform the task with or without an accommodation for the purpose of RTW, modified or otherwise. Physician must release employee to RTW for this analysis and on-site testing. On-site time: Approximately 4 hours; 2 visits recommended

Non-Occupational Medical Ergonomic Worksite Analysis

WI’s Non‐Occupational Medical EWA service can be prescribed by an employee’s physician or requested directly by the employer to assist with accommodating an individual with a diagnosed medical condition (no workers’ compensation claim). We utilize the same features found in the Preventive EWA but offer more detail specific to minimizing aggravation of the medical condition while supporting the employee in achieving the essential functions with reasonable accommodations. This evaluation is a preventive approach to FEHA/ADA and FMLA needs where there are no legal or performance factors involved. On-site time: Approximately 2 hours

Follow Up Visit (to prior eval)

Our Follow Up visit assures the employer, employee, physician and insurer that the initial evaluation (preventive, MO (WC), Indemnity (WC) or other assessment was implemented to the extent feasible to achieve the expected outcomes. We review the recommendations to validate implementation, assure correct set up of all tools and educate the employee on proper use of new products provided to support SAW/RTW. We provide a report of findings and any additional recommendations to support closure of the case. On-site time: 1‐2 hours

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