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Ergonomics Assessment Request

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Ergonomics Assessment Request

Ergonomics Assessment Request

"*" indicates required fields

Employee Name

First Last

Date*

MM slash DD slash YYYY

Building Name*

Office Location*

Department

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

MM slash DD slash YYYY

Have you been diagnosed by a physician/DO as having an injury*

Yes

No

How long have you had this condition?

Have you had:*

Surgery

Physical Therapy

Non-traditional Therapy

N/A

Self-Assessment Checklist*

Max. file size: 50 MB.

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Phone: 706-542-5801

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