Assessment Request Form NameThis field is for validation purposes and should be left unchanged.Requestor InformationI am authorized to request services for the employee listed, and the below referred business and all my acts shall be binding on the businessRequester(Required) I am an "Authorized Requestor" for my company. I am an individual. not company affiliated. I am am a Vocational Counselor / Case Manager. If we are sending the invoice to your company please continue with this form.If we are sending the invoice to Washington State Labor and Industries please use the form found here: L&I Assessment RequestRequestor Company(Required)Authorized Requester(Required) First Last Authorized Requester Email(Required) Enter Email Confirm Email Authorized Requester Phone(Required)Please enter a 10 digit North American phone number. (XXX) XXX-XXXXEmployee InformationCompany(Required)This field is hidden when viewing the formAssessment / Evaluation Type(Required) Office Laboratory Both (Office & Lab) Other Evaluation Type(Required) Ergonomic Screening (Aggregated report) - 25 to 30 minutes. In-person screens have a 2-person minimum. Ergonomic Assessment (Full report) - 60 to 90 minutes Phone Coaching (No report) - 25 to 30 minutes Evaluation(Required) In-Person Via Telephone Conference Via WebEx Conference Via What'sApp Conference Evaluation(Required) Via Telephone Conference Via WebEx Conference Via What'sApp Conference Facility / Office(Required)Please provide the facility name and / or office number where your employee is located.Facility Type(Required) Healthcare Clinic Room Home Office Laboratory Office Vehicle Other Location Address(Required)Please provide the location address where your employee is to be seen. Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Employee Name(Required) First Last City(Required)State / Province(Required)Employee Phone(Required)Employee Email Address(Required) Time Zone(Required)NewfoundlandAtlanticEasternCentralMountainPacificAlaskaHawaiiOtherIf Other:(Required)If Other was chosen for the Employee Time Zone, please Tell us where the employee is located.Additional Comments / InformationUpload Additional InformationUpload any additional information (previous job analysis, doctor's note, etc.) in .pdf, .doc or .docx format. Maximum Number of Files: 3 Maximum File Size: 25MB Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 25 MB, Max. files: 3. Δ
