Atlas Injury Prevention Solutions Service Provider Profile

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* 1. Date

Today's Date

Date

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* 2. Have you signed an Atlas Network Partner Agreement?

Yes

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* 3. Clinic Information

Clinic Name

Address

City

State

Zip or Postal Code

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* 4. Who would you like Atlas to contact about service opportunities at your clinic?

Contact Name

Contact Email

Contact Phone

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* 5. Please list up to 30 cities or towns you are willing to travel to within a 30 minute drive one-way. This will assist us in sourcing opportunities that are in your area.

City/Town 1

State 1

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State 2

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State 5

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State 30

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* 6. Current Staff Education (choose all that apply)

Physical Therapist (PT)

Occupational Therapist (OT)

Physical Therapy Assistant (PTA)

Certified Athletic Trainer (ATC)

Certified Occupational Assistant (COTA)

Exercise Physiologist

BS in Fitness Management

Kinesiologist

Certified Strength and Conditioning Specialist (CSCS)

CPR Certification

Certified Ergonomist (CPE)

Non-Certified Ergonomist

Other (please specify)

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* 7. Current Service Offerings (choose all that apply)

Job Demands/Essential Function Analysis

Physical Function Pre-employment Screens

Physical Function Pre-employment Screen Development

Office Ergonomics

Industrial Ergonomics

Transportation Ergonomics

Transportation Wellness

Safe Patient Handling Ergonomics/Risk Assessment

Onsite Early Intervention

Onsite Physical Therapy

Functional Capacity Exams

Drug Testing

Corporate Wellness Program

DOT Testing

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* 8. Please list testing equipment that is currently available or the clinic is willing to purchase at no cost to Atlas Ergonomics (choose all that apply)

BP Cuffs (Standard, Large, XL)

Stethoscope

Height Measuring Tool

Pulse Oximeter

Heart Rate Monitor (i.e. Polar)

400 lbs. Scale

12" High Step

Metronome

Force Gauge (i.e. Shimpo or Chatillon)

Wall Mount and Push/Pull Bar for Force Gauge

Lifting Crate

Various Sized Weights (Plates, Cuffs or Dumbbells)

6'-10' Step Ladder

2 - 5 Gallon Bucket/Sand

Shelving/Lifting Station

12' Balance Beam (4"x6" Wide and Elevated 4")

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* 9. Do you have adequate parking space for a semi-truck cab and/or trailer either at your clinic or an adjacent parking lot?

Yes