Ergonomics Services Request Form

Managers and supervisors are responsible for conducting ergonomic evaluations for their employees as per P&P 290-16

Participation by the manager/supervisor is required in order to perform an ergonomic evaluation of the employee's workstation. Employees desiring an ergonomic evaluation will need to contact their supervisor.

If you work at the UC Davis Health System in Sacramento, please contact Michael Galang to request an ergonomic evaluation of your workstation:
Section A: Supervisor Information
Supervisor Name
Is the employee currently under medical care for a repetitive motion injury?
Has a workers' compensation claim been filed?
Has a Tier 1 Ergonomic Evaluation been performed?
Section B: Employee Information
Employee Name
Section C: Type of Ergonomic Service Requested
Please indicate which type of ergonomic service you are requesting:
Focused evaluation of workstation's components such as sit/stand or if an urgent visit is needed.
Comprehensive evaluation of workstation.
To test keyboards, mice, and sit/stand demos.
This is a quick evaluation for more than two employees at the same location.
If your office is moving to a new location and need to pre-adjust the workstations.
Evaluation of any work processed other than office environment.
Basic ergonomics for computer users.
Section D: Concern or Service Requested
Your Department Safety Coordinator's (DSC) Information
Your DSC's Name:
Your DSC will be emailed a copy of this request.