CSU Ergonomic Assessment
Referral Form
CSU STAFF DETAILS
Name:
Position:
Faculty/Division:
Campus:
Telephone:
Email:
Manager / Supervisor:
Telephone:
Email:
Please indicate working day and hours:
DAY:
Monday
Tuesday
Wednesday
Thursday
Friday
HOURS:
INJURY DETAILS
Injury:
Date of injury onset:
Currently undertaking treatment:
Yes
No
DEPARTMENT RESPONSIBLE FOR PAYMENT OF ACCOUNTS
Name:
Position:
Department:
Address:
Telephone:
Email:
APPROVAL is hereby given to RehabCo to undertake the following service
ERGONOMIC WORKSTATION ASSESSMENT/S as indicated below:
$220 for 1 assessment
$380 for 2 assessments
$510 for 3 assessments
$600 for 4 or more assessments
(maximum 6)
Number of assessments required:
The above prices are GST exclusive and includes scheduling of appointments; assessment/s; education; modification to workstation, report and up to 30
minutes of travel ; Travel over 30 minutes is charged at a hourly rate of $170.00
COMMENTS:
CSU APPROVAL BY:
Name:
Signature:
Department:
Position:
Telephone:
Email:
EMAIL FORM TO REHABCO
Date: