Ergonomic Evaluation Request Form

Ergonomic Evaluation Request Form

Employer Entity*

Please select the entity to which you are employed

Select

If you are employed by Stanford Medicine Children's Health:

Please follow this link to complete the appropriate ergonomic evaluation request form for SMCH.

If you are employed by Stanford Medicine Partners:

Please consult with your manager to complete the appropriate ergonomic evaluation request form for SMP. Requests for SMP employees are submitted by management only via the SMP EH&S Home Page.

Legal Last Name*

Please enter your last name as it appears on legal documents

Legal First Name*

Please enter your first name as it appears on legal documents

Phone Number*

Please enter your cell or best contact number

Stanford Email*

Please use your Stanford email address

You Work:*

Do you work on-site or from home?

Select

On-Site Address*

Please provide the address where you work

Select

Other Work Address

Suite Number and Desk Location*

If you work on-site, please tell us how to find your desk. Example: Landmark to help us find you.

Job Tasks*

Please select the closest general description of your job

Select

Job Task Other

Job Title*

Please tell us your job title

Department*

What department do you work for?

Shift Days/Hours

What hours or shift do you work?

Cost Center Number

If you know your cost center, please enter it

Manager Name

What is your manager's name?

Manager Email

If you know your manager's email, please enter it

Training Completed?*

Have you completed the ergonomic training?

Select

SREO Completed?*

Have you completed an incident report (SREO)?

Select

Previous Eval?

Have you had an ergonomic evaluation before?

Select

Date of Previous Eval

Request Type*

What prompted your request?

Select

Request Description

Referred by:

Select or enter value

Referring Clinician Name

Referring Clinician Email

Additional Information

Send me a copy of my responses

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