Ergonomic Workstation Evaluation Request

Purpose

[Company Name] is committed to providing employees with workstations which are free from known or potential hazards and will allow employees to be productive and comfortable. [Company Name] also recognizes and appreciates that to be effective employees may at times need differently configured workstations due to an injury or an accommodation in accordance with the American with Disabilities Act (ADA).

For [Company Name] to best determine whether an employee's workstation is appropriate or if the workstation arrangement needs to be modified, employees must request an ergonomic evaluation of their workstation by completing the form below.

Directions and Procedures:

Employees must complete all information on the request form and submit it to his or her immediate supervisor. Incomplete forms will be returned. Supervisors must review the request for accuracy, attach a copy of the employee's job description and submit both to HR within 5 business days.

Within 5 business days of receipt of the employee's request, HR will review the request and communicate with the employee regarding the status of the request.

Employee Information

Employee Name (Please print or type):

Title:         

Supervisor:                   

Work Location:

Reason for Request

I am requesting an ergonomic evaluation of my workstation due to the following (check all which apply):

__ I am experiencing pain or numbness when engaged in activities at my workstation.

__ My healthcare provider has recommended that an evaluation of my workstation be conducted because of a work-related injury. (Please attach related documentation from your healthcare provider).

__ My healthcare provider has recommended that an evaluation of my workstation be conducted because of a non-work injury or disability. (Please attach related documentation from your healthcare provider).

__ Other reasons (please be as specific as possible)

Please describe your work duties and how your current workstation arrangement affects your ability to perform them:

Approvals:

Supervisor Name (Printed):

Supervisor Signature:                                                 Date:

HR Representative Name/Title (Printed):

HR Representative Signature:                                    Date: