University of California, Riverside

Ergonomics



Ergonomic Evaluation Form


Instructions: Use this form to request an Ergonomic Evaluation. All fields are required to be completed. This service is available to employees only.

Name:
Phone:
Email:
Physical Location
(Bldg. name/number and room number):
Job Title:
Supervisor:
Type of Request Ergonomic workstation evaluation
Seating evaluation
Information and demonstration of ergonomic office equipment
Reason(s) for Request I experience discomfort (associated with my workstation)
I have a new workstation or I am new to the job
I want to ensure my workstation is set up ergonomically correct
Other (please specify)
Please identify your primary work tasks
(check all that apply)
Computer use
Phone calls (making and/or receiving)
Deskwork / Paperwork
Filing
Other (please specify)
When you are using a computer, what percent of your workload:
Requires keyboarding? %
Is mouse-intensive? %
Comments (optional)
     

For assistance with this form, please contact Ergonomics (951) 827-3010.

More Information 

General Campus Information

University of California, Riverside
900 University Ave.
Riverside, CA 92521
Tel: (951) 827-1012

Department Information

Human Resources
1201 University Ave., Suite 208
Riverside,CA 92507


Fax: (951) 827-2672

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