Ergonomic Accommodation Workstation Request Form
The procedure at the local is that a form must be submitted to HR in order to start the process. Please complete the entire form and be as specific as possible.

If you have not yet submitted your medical note to HR:
Your medical note should be emailed to hrdepartment@seiu1021.org within 48 hours of submitting this form so that your request can be completed in a timely manner.

Email address *
Primary office location *
Do you require a work station ergonomics evaluation? *
Describe your request for a work station evaluation *
Your answer
Describe the specific issue which has lead to your request *
Your answer
Describe any requested ergonomic equipment in detail *
Your answer
Do you have a medical note? *
A copy of your responses will be emailed to the address you provided.
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