Ergonomic Evaluation Request

Employees may find the CSU – Computer Workstation Ergonomics training of assistance while awaiting an ergonomic assessment.

Equipment recommended as a result of an ergonomic assessment may be purchased by the employee’s department.

Employee Information

First Name: * *

Last Name: * *

Email: * *

Extension: * *

Job Title: *

Department: *

Work Location: * *

Manager 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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