Request Ergonomic Equipment

NOTE: Environmental Health and Safety Web-Based Online Ergonomics Course (EHS 3400) MUST be completed before requests are submitted. Requests must be made within 30 days of the evaluation.

* indicates required fields.

Name of Requestor *

Date of Workstation Evaluation *

Evaluated By *

Mike Fonda

Nikhil Sastry

EHS 3400 "Ergonomics - Computer Workstation" Course Completion Date *

Supervisor's Name *

First *

Last *

Supervisor Approved Request *

Yes

Have You Requested a Loaner *

Yes

Upload Evaluation with Suggested Equipment *

Email *