Ergonomic Intake Form

Office of Risk Management Ergonomic Intake Form

Risk Management offers in person or remote ergonomic assessments to employees in all State departments. Ergonomic assessments are not needed if an employee moves to a new workstation or if a sit/stand desk is being ordered for them. Any ergonomic assessment provided for home office use will be done remotely.

Risk Management pays for ergonomic assessments. There is a significant cost to Risk if the employee cancels or does not show up for the assessment on the scheduled date and time. Please ensure that your employee attends the scheduled ergonomic assessment. If your employee cannot attend, then please have them provide as much advanced notice as possible.

Once the assessment is complete, a report will be sent with the recommended furniture or equipment. The Department is responsible for covering the cost of any purchases made. Please contact Breanna Reynolds with questions. Breanna.L.Reynolds@vermont.gov

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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