Ergonomic Assessment Prescreening Survey

  • Date Format: DD slash MM slash YYYY
    0=No Pain 10=Extreme Pain
    If yes, please provide details on quantity and frequency
    If yes, please provide details on quantity and frequency
    If yes, please provide details on quantity and frequency
    If yes, please provide details below:
  • Date Format: MM slash DD slash YYYY
  • DISCLOSURE

    The information collected on this prescreening survey is collected for the purpose of an ergonomic assessment. It will form part of your employee record.

    If any information requested is not provided, it will impact on the assessment and recommendations.

    Our Privacy Statement is available by contacting Enriched Heath Care or visiting Enriched Health Care’s Website (www.enrichedhealthcare.com.au). If you have any queries about privacy, you can contact our Health Care Services Manager via email support@enrichedhealthcare.com.au

  • CONSENT & DECLARATION

    I acknowledge and agree that the information provided by me in this form and any other information that I may subsequently provide may be disclosed to: 

    • Any entity involved in any restructure or transfer of Enriched Heath Care;
    • Enriched Pty Ltd and any related bodies corporate of Enriched Heath Care; or
    • Employees, agents or contractors or other service providers of Enriched Heath Care who reasonably require access to the information
    • My employer
  •  For the purpose of enabling Enriched Health Care to complete an ergonomic assessment and any other assessments deemed reasonable and necessary
  • By Signing below, you consent to participate in assessments administered by Enriched Health Care staff and consent for Enriched Health Care to share medical or other information with your employer, other contacts and health care providers where relevant?