

	Phone: 866.535.6210 Email: info@siteergonomics.com

Overview | Post Injury Evaluations | Ergonomic Presentations | Preventative Assessments |
Train-the-Trainer Program

INTERMEDIATE EVALUATION

Intermediate Evaluation: The goal of the Intermediate Evaluation is to take a more detailed look at the workstation. This evaluation is designed for employees who are currently being treated by a physician but do not have a work comp case. The Intermediate Evaluation takes approximately 45 minutes.

Intermediate Evaluation Order Form

Employee Information
Name:
Employee Phone:
Physician Information
Physician:
Clinic:
Medical Record #:
Telephone:
Address:
Employer Information
Employer:
Contact Person:
Telephone:
Address:
Requested by:	Physician Employer
Special Requests:

INTERMEDIATE EVALUATION

Intermediate Evaluation Order Form

Employee Information