Workplace Ergonomic Assessment Request

Workplace Ergonomic Assessment Request — Form Fields

This hr template includes 12 fields. Request for professional ergonomic assessment of an employee's workstation. Free to customize and use on ZenBuild.

• Employee Name (text, required)
• Email (email, required)
• Department (text, required)
• Office Location and Desk Number (text, required)
• Work Setup (dropdown selection, required) — options: Office Desk, Standing Desk, Hybrid (home and office), Fully Remote, Lab/Workshop
• Current Discomfort Areas (checkboxes, optional) — options: Neck, Shoulders, Upper Back, Lower Back, Wrists/Hands, Eyes/Vision, Hips, Knees, None
• Hours at Workstation Per Day (dropdown selection, required) — options: Under 4, 4-6, 6-8, 8+
• Currently Using Ergonomic Equipment (multiple choice, required) — options: Yes, No
• Current Chair Type (text, optional)
• Dual Monitor Setup (multiple choice, optional) — options: Yes, No
• Urgency (dropdown selection, required) — options: Preventive (no current issues), Mild Discomfort, Moderate Pain, Doctor Recommended, Workers Comp Related
• Describe Specific Concerns (long text, optional)