Ergonomic Intake Form

Office of Risk Management Ergonomic Intake Form

Today's Date

Form Completed By

Employee Name (Last/First)

Employee Email Address

Employee State ID #

Employee Phone #

Employee Job Title

Employee Department

Employee Division

Workplace Street Address

Physical Location (Building Name, Room #, etc.)

City

Supervisor Name (Last/First)

Supervisor Phone #

Supervisor Email Address

HR Administrator Name (Last/First)

HR Administrator Phone #

HR Administrator Email

Why is an assessment being requested?

Note: Please be advised that ergonomic assessment is not required for Sit/Stand Workstations.

How long have you been using this workstation?

Have you had an evaluation before?

Yes

Date of previous evaluation

Describe the reason for your request

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.