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WORKSTATION ASSESSMENT REQUEST FORM

PART 1 – TO BE COMPLETED BY ORGANISATION REQUESTING ASSESSMENT

 

Organisation Contact Name 
Email Phone 
EMPLOYEE(S) REQUIRING ASSESSMENT (please attach separate list if Quick Check assessments are to be conducted on more than one employee).
Name Phone 
Branch Email 
Location (Include Building, Floor & Street Address) 
PLEASE TICK ONE OF THE FOLLOWING ASSESSMENT TYPES

ÿ

Quick Check: approx. 15min

duration - Correct set up of

workstation.

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Standard: approx. 30min duration -

 

Experiencing a physical discomfort while at your workstation. 

ÿ

Specialist: approx 45-60mins duration -

 

History of health concerns that are impacting on you / the employee in the workplace.
Brief description of concerns where applicable? 
Supervisor’s name Signature 
Phone Email 

PART 2  - INVOICING DETAILS – PLEASE COMPLETE

Contact Details (name):
Business Group/Division/Branch
Phone: Email:

PART 3  - TO BE COMPLETED BY SRC SOLUTIONS

Date Received Consultant Name 
Assessment DetailsDate:  
Time:  
Location:  
             
Cancellation Policy:  If you need to cancel your appointment, please notify SRC Solutions as soon as possible but no later than 4.30 pm on the working day prior to your scheduled appointment.  Any cancellations made on the day, or at the time of the appointment, will incur a fee equivalent to our minimum call-out fee of 2 hours which will be charged to your department. 

 

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