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

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Job Title:
Supervisor:
Type of Request:	Ergonomic workstation evaluation Seating evaluation Information and demonstration of ergonomic laboratory 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)	Benchwork Hand Tool Use Microscope work Pipetting Test Tube Handling Other (please specify)*
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For assistance with this form, please contact Ergonomics (951) 827-5528.