Ergonomic Intake Form

Office of Risk Management  Ergonomic Intake Form

Today's Date *

Day Day12345678910111213141516171819202122232425262728293031

Month MonthJanFebMarAprMayJunJulAugSepOctNovDec

Year Year20192020202120222023

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 Year20192020202120222023

Describe the reason for your request *