ࡱ> EGD nbjbj 16jjM lzzzzzzz8,T^~lT,-//////$ SizSzzzz--<zzR OuB ,0,rrzzzz Office of the State Employer Employee Health Management REQUEST FOR AT - RISK ASSESSMENT Date:  FORMTEXT       ________________________________________________________________________________________ Department Authorized:  FORMTEXT       Phone #: FORMTEXT       Representative Employee: Classification: Work Location: City: FORMTEXT       ______________________________________ FORMTEXT       ______________________________________  FORMTEXT       ______________________________________  FORMTEXT      Employee I.D.#:  FORMTEXT       _________________________________ Employee s Phone #: FORMTEXT       _________________________________ Date of Injury:  FORMTEXT       _________________________________Zip Code:  FORMTEXT      Department:  FORMTEXT       _________________________________________________ Supervisor:  FORMTEXT       Agency/Division:  FORMTEXT       _____________________________________ Supervisor s Phone #: FORMTEXT        Note: If this assessment is related to Workers Compensation (WC), Long-Term Disability (LTD) or American with Disabilities Act (ADA), please telephone Employee Health Management (EHM) for guidance at 517- 241- 9090. If during the AT-Risk assessment, a referral to WC, LTD or ADA becomes appropriate, the evaluation will be suspended and EHM will contact the employees department. SERVICES REQUESTED  FORMCHECKBOX Advanced/Comprehensive Ergonomic Assessment (chair & work station/space assessment)  FORMCHECKBOX Office/Task Chair Assessment (chair evaluation only)  FORMCHECKBOX Ergonomic Assessment (work station/space assessment only)  FORMCHECKBOX Other:  ADDITIONAL INFORMATION (Attach medical):  FORMTEXT      FOR EMPLOYEE HEALTH MANAGEMENT USE ONLY:Date Received: ________________________ EHM referral #:  FORMTEXT       Request for Assessment is: FORMCHECKBOX Approved FORMCHECKBOX Denied At Risk Disclosure Statement This disclosure statement is to inform you that the medical information you provide may be shared with your department, Employee Health Management, Michigan Rehabilitation Services/Accommodations Center, Department of Information Technology or any third party service provider for the purpose of addressing your ergonomic evaluation request. The medical information you provide and related documentation is necessary to clarify and expedite the ergonomic evaluation, and will be handled in a confidential manner. I have read and acknowledged that my medical information will be shared strictly for the purpose of my ergonomic evaluation. 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