Ergonomic Evaluation Request

Please note: due to staff availability, there will be a delay in scheduling ergonomic assessments. Employees may find the CSU – Computer Workstation Ergonomics training of assistance while awaiting an ergonomic assessment.

Employee Information

First Name: * *

Last Name: * *

Email: * *

Extension: * *

Job Title: *

Department: *

Work Location: * *

Manager/Supervisor Information

Required for on-site evaluation

First Name: * *

Last Name: * *

Email: * *

Extension: * *

Additional Information

Reason for Request: *

Employee concern about workstation set up
Employee concern with physical discomfort
New or revised process, procedure or task
Safety concern
Relocation of work station
Follow up to prior evaluation
Other

Email CC (Optional): *

Comments (Optional): *

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