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

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