Employee Name First Last Today's Date Building Name Office Location Department Employee Title Title Title - None -MissMsMrMrsDrOther… Enter other… Employee Campus Email Employee Office Phone # Supervisor Name First Last Supervisor Email Supervisor Office Phone # Reason for requesting an Ergonomics Evaluation Employee concern about workstation set up. Employee concern with physical discomfort. New or revised process, procedure or task. New hire (attended Office Ergo Training last 90 days). Safety concern. Relocation: Check past eval report for set-up details and preferences). Follow-up to prior evaluation. Other. If you have an existing Workers Comp claim, please specify the date it was filed Have you been diagnosed by a physician/DO as having an injury Yes No If YES, can you share that diagnosis? Yes No N/A How long have you had this condition? Have you had: Surgery Physical Therapy Non-traditional Therapy N/A Self-Assessment Checklist One file only.5 MB limit.Allowed types: pdf. Leave this field blank
