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Ergonomic Assessment

Ergonomic Assessment
Full Name
Area of Work
Building Name
Room Number
Phone Number
Supervisor
Status
 Staff Postgraduate
Concern and reason for assessment request.
Discomfort scale: On a scale of 0- 10 how would you rate your discomfort?(Click on a number)
 1 2 3 4 5 6 7 8 9 10
Availability for an assessment in the next ten working days
1st Choice
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Second Choice
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Third Choice
 :
Impact on work
 
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