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.

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

Request Description

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

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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