

	Phone: 866.535.6210 Email: info@siteergonomics.com

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

POST INJURY EVALUATIONS

Post Injury Evaluation: The goal of the Post Injury Evaluation is to do a comprehensive evaluation to minimize further injury and assist the treatment of employee with an open worker's comp claim. This evaluation is recommended for employees with multiple injuries and employees who have an open worker's comp claim. The Post Injury Evaluation takes at least 60 minutes per employee.

Post Injury Evaluation Order Form

Post Injury Follow Up
Employee Information
Name:
Employee Phone:
Claim Number:
Date of Loss/Injury:
Physician:
Clinic:
Medical Record #:
Telephone:
Address:
Employer Information
Employer:
Contact Person:
Telephone:
Address:
Insurance Information
Insurance Company:
Claims Adjuster:
Telephone:
Address:
Requested by:	Physician Insurance Adjuster Employer
Special Requests:

Post Injury Evaluation Order Form

Employee Information