Workplace Ergonomics Assessment Request Form

Workplace Ergonomics Assessment Request Form — Form Fields

This operations template includes 11 fields. Allow employees to request an ergonomics assessment for their workstation to prevent injury and improve comfort. Free to customize and use on ZenBuild.

• Employee Name (text, required)
• Employee Email (email, required)
• Department (text, required)
• Manager Name (text, required)
• Work Setting (dropdown selection, required) — options: Office, Home office, Hybrid
• Primary Equipment Used (dropdown selection, required) — options: Desktop computer, Laptop, Dual monitors, Single monitor, Standing desk already
• Main Concern (dropdown selection, required) — options: Neck/shoulder pain, Back pain, Wrist/hand pain, Eye strain, General discomfort, Preventative - no current pain
• Describe your current workstation setup (long text, required)
• Have you had ergonomics training before? (dropdown selection, required) — options: Yes, No
• Priority (dropdown selection, required) — options: Urgent (pain affecting work), Standard, Just preventative
• Additional notes (long text, optional)