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About the Agency
Agency Departments
Chief Performance Office
Financial Services Division
Office of Racial Equity
Office of Risk Management/Liability Claim Forms/Workers' Comp.
Auto and General Liability Claim Forms
Insurance Specifications, Reporting Claims, The Claim Process, Requesting Certificates and Review of Insurance Requirements for contracts and grants
Workers' Compensation, Safety & Training
Contact Us
Medical Billing Address
Designated Health Facilities for WC Injuries
Ergonomic Intake Form
Frequently Asked Questions
Helpful links to safety websites
Injury Reporting
Workers' Compensation Forms
Workplace Safety Training
VT RETAIN
Secretary's Biography
Secretary’s Directive Memos
Administrative Bulletins
Boards and Commissions
Button Up Vermont
Career Opportunities with the State of Vermont
COVID-19 Informational Resources
Fiscal Transparency
Public Information, Meetings and Reports
Strategic Plan
Vermont Flood Resources
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State Employee Workers' Compensation, Safety and Training
Ergonomic Intake Form
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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?
- Select -
Select One
New Employee
Workstation Move
Workers' Compensation Claim
Personal Medical Accommodation
Request for Sit/Stand Workstation
Home Office
General Ergonomic Concerns
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
No
Date of previous evaluation
Describe the reason for your request
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