Campus Safety | CSUF - Environmental Health and Safety

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

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Comments (Optional): *

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Ergonomic Evaluation Request