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Instructions: Use this form to request an Ergonomic Evaluation. All fields are required to be completed. This service is available to employees only.

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Job Title:
Supervisor:
Type of Request	Ergonomic workstation evaluation Seating evaluation Information and demonstration of ergonomic office equipment
Reason(s) for Request	I experience discomfort (associated with my workstation) I have a new workstation or I am new to the job I want to ensure my workstation is set up ergonomically correct Other (please specify)
Please identify your primary work tasks (check all that apply)	Computer use Phone calls (making and/or receiving) Deskwork / Paperwork Filing Other (please specify)
When you are using a computer, what percent of your workload:
Requires keyboarding?	%
Is mouse-intensive?	%
Comments (optional)
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For assistance with this form, please contact Ergonomics (951) 827-5528.