University of California, Riverside

Ergonomics



Matching Funds Request Form


Instructions: Complete this form to submit a request for matching funds. This form must be completed prior to purchasing any ergonomic equipment and all fields are required to be completed. The form must be completed for EACH piece of equipment for which funds are being requested. This service is available to UCR staff and faculty only.
Name of employee (for whom this equipment is being requested):
Employee's department:
Has the employee completed Ergo iSEAT? Yes
No
Was an in-person evaluation completed by the ergonomics program
for this employee?
Yes
No
If so, please provide the date of the onsite ergonomic evaluation:
Type of equipment requested:
Please provide the name of the equipment.
          Make:
          Model name or #:
Total cost of the equipment (including tax and shipping):
Name of the employee submitting this request:
Email of the person submitting this request:
     

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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