Ergonomic Evaluation Request Form Date: Employee ID #: Employee First Name: Employee Last Name Employee Email: Employee Title: Employee Department: Employee Phone: Building & Room/Cubicle Number: Street Address: City State, Zip: Working Hours: Manager: Manager Email: Manager Phone: Onsite Evaluation Ergo Lab Visit Request Type: (check reason): New Hire Group Training Physical Discomfort or Consultation Only Change in Physical Condition (space planning, furniture/ product selection) Relocation Workstation or Safety Concern Are you a current Workers’ Workers’ Compensation Compensation or OHF Referral? Occupational Health Facility (OHF) Referral Comments: All employees requesting ergonomic assistance are asked to complete , a web-based ergonomics training and risk assessment survey. BruinErgo must be completed prior to having an on-site evaluation. Program staff will review your self-risk assessment results and contact you and/or your manager to discuss appropriate next steps. Print and/or email form to
Ergonomic Evaluation Request Form Date: Employee ID #: Employee First Name: Employee Last Name Employee Email: Employee Title: Employee Department: Employee Phone: Building & Room/Cubicle Number: Street Address: City State, Zip: Working Hours: Manager: Manager Email: Manager Phone: Request Type: Onsite Evaluation (check reason): New Hire Physical Discomfort or Change in Physical Condition Relocation Workstation or Safety Concern Ergo Lab Visit Group Training Consultation Only (space planning, furniture/ product selection) Are you a current Workers’ Compensation or OHF Referral? Workers’ Compensation Occupational Health Facility (OHF) Referral Comments: All employees requesting ergonomic assistance are asked to complete , a web-based ergonomics training and risk assessment survey. BruinErgo must be completed prior to having an on-site evaluation. Program staff will review your self-risk assessment results and contact you and/or your manager to discuss appropriate next steps. Print and/or email form to
Ergonomic-Evaluation-Request-Form-Ambulatory-protected-r1.docx