Ergonomic Evaluation Request Form

To help us fulfill your request, please complete this form as accurately as possible. A representative will respond in 2 business days.

Today's Date*

Requestor Information

Your Name*

First and last name

Stanford Children's Email Address*

Best Contact Number*

This is for scheduling an evaluation or equipment deliveries

Phone

Office Location*

Onsite

Home Office

Hybrid

Address*

ONSITE STAFF: Please enter the exact address where you would like equipment delivered, or this may cause significant delays. Include a room number or workstation number.

HYBRID STAFF: Only enter the address where you need an assessment.

Workstation Images

Please upload 3 images of your home office workstation to assist our evaluator(s). 1. A side view of you sitting at your desk, with your hands on the keyboard/mouse 2. A side view of you sitting in your chair, showing all of the chair 3. An overall picture of your workstation from behind, without you in the picture, showing the entire desk, monitors, keyboard/mouse, etc.

Drag and drop files here or

Job Information

Job Tasks*

Clinical

Non-Clinical

Organization*

LPCHS

PCHA

Employee Title*

Department*

Cost Center Number*

NOTE: Please use the new 11-digit cost center number in Workday. Please ask your manager or admin if you need help.

Manager Name*

Manager Email*

Request Information

Request Type*

Select or enter value

Request Description*

Type a brief description of the issue and any steps you've taken to address it.

Type of Discomfort*

Please indicate the main area where you have discomfort.

Eyes/Head

Neck/Upper Back

Shoulders

Mid Back

Lower Back

Arms

Wrists/Hands

Knees

Legs

Evaluation/Training History

Have you completed the online office ergonomics training module?*

Yes

Have you previously had an ergonomic evaluation?*

Yes

If yes, please provide the date of your previous assessment

Send me a copy of my responses

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