Office of Risk Management Ergonomic Intake Form Today's Date * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year20162017201820192020 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 OneNew EmployeeWorkstation MoveWorkers' Compensation ClaimPersonal Medical AccommodationRequest for Sit/Stand Workstation 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 Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year20162017201820192020 Describe the reason for your request *