Ergonomic Evaluation Request Form
Instructions: Use this form to request an ergonomic evaluation. This service is available to employees only.
Email address *
Name *
Your answer
Supervisor *
Your answer
Have you discussed this request with your supervisor? *
Type of Request *
Reason(s) for Request *
Required
Please identify your primary work tasks (check all that apply) *
Required
How many hours (on average) do you use your workstation each day? *
Your answer
When you are using a computer, what percent of your workload:
Requires keyboarding? *
Your answer
Is mouse-intensive? *
Your answer
Comments
Your answer
A copy of your responses will be emailed to the address you provided.
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