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Matching Funds Request Form
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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:
Mouse
Keyboard
Keyboard tray
Wrist support
Monitor arm
Monitor riser
Back support
Chair
Furniture
Laptop stand
Sit-Stand solution
Phone accessory
Document holder
Footrest
Other
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.
