Ergonomic Modification & Assistive Tech Evaluation Form

Employee Full Name

Employee Identification Number

Official Job Title

Primary Department or Business Unit

Direct Supervisor or Manager Name

Supervisor Email Address

Employee Corporate Email Address

Employee Direct Phone or Extension

Employee Hire Date in Current Role

Total Tenure with Organization (in months)

Employment Classification

Primary Work Arrangement

Please specify hybrid schedule details (days per week on-site, remote work location address):

Please provide full remote work location address for potential equipment shipping:

Physical Workstation Building or Campus Name

Floor Number and Wing/Zone

Desk Number or Workstation Identifier

Workstation Physical Configuration

Describe Current Standard Equipment Provided (monitor count/type, chair model, keyboard, mouse, desk type):

Has the employee received any previous ergonomic modifications or accommodations?

Detail previous accommodations provided, dates, and effectiveness:

Date of Formal Medical Diagnosis

Primary Diagnosed Condition Category

Affected Body Regions (select all applicable)

Treating Healthcare Provider Full Name and Credentials

Healthcare Provider Clinic or Hospital Name

Provider Contact Email or Phone for Verification

Upload Medical Documentation (diagnosis letter, functional capacity evaluation, restrictions list)

Current Symptom Severity Assessment - Rate the average pain/discomfort level experienced during typical work tasks over the past two weeks

Functional Workspace Restrictions - Please indicate the level of limitation for each activity

Are the current restrictions considered temporary or permanent by the healthcare provider?

Expected date for medical re-evaluation and potential clearance:

Provide healthcare provider's statement on permanency and long-term prognosis:

Detailed Description of Work-Related Activities That Aggravate Symptoms:

Has the employee been prescribed physical therapy or rehabilitation?

Detail therapy frequency, duration, and any work-hardening recommendations:

Are there any recommended phased return-to-work or reduced hours protocols?

Specify recommended schedule and duration:

Has a professional ergonomic assessment been conducted at the employee's workstation?

Upload Professional Ergonomic Assessment Report:

Is a professional ergonomic assessment being requested as part of this accommodation?

Categories of Specialized Equipment Requested (select all applicable)

Detailed Equipment Request Specification and Justification Matrix

Are there specific vendor preferences or models recommended by the healthcare provider or ergonomist?

Provide vendor details, model numbers, and rationale for preference:

Will the employee require training or orientation on proper use of new ergonomic equipment?

Describe training needs, preferred learning method, and time availability:

Is there a need for a trial period or pilot testing of equipment before permanent procurement?

Specify trial duration, success metrics, and evaluation criteria:

Are the requested modifications compatible with existing IT infrastructure and software platforms?

Describe compatibility concerns and required IT upgrades:

Have alternative or lower-cost solutions been considered and evaluated?

Describe alternatives considered and why they were deemed insufficient:

I confirm that the equipment requested directly addresses specific functional limitations documented in the medical assessment and is not for general comfort enhancement.

Has a physical site audit been conducted at the employee's workstation location?

Upload Site Audit Photographs and Measurements Document:

Provide preliminary space constraints and measurements (desk dimensions, clearance space, power outlet locations):

Environmental Factor Assessment - Rate current workstation conditions

Will electrical or data cabling modifications be required to support new equipment?

Detail required electrical work, data ports, or cable management solutions:

Will the installation require facilities or maintenance team involvement (e.g., desk disassembly, wall mounting)?

Describe facilities work needed and estimated labor hours:

Will the accommodation affect adjacent workstations or shared workspace configurations?

Describe impact on neighbors and any required relocations:

Comprehensive Budget Allocation and Cost Analysis

Total Estimated Investment for Full Accommodation

Budget Approval Status

Requested Implementation Completion Date

Is there an urgent business need to expedite this accommodation (e.g., employee is currently on leave)?

Critical deadline date:

Cost-Benefit Justification: Explain how this accommodation will improve productivity, reduce absenteeism, and prevent further injury-related costs:

Assigned HR Business Partner Name

HRBP Initial Review Date

Does this request comply with organizational accommodation policies and precedents?

Describe policy deviations and required escalations:

Has a consistent accommodation approach been applied compared to similar cases in the organization?

Explain rationale for differential treatment if applicable:

Are there any potential precedents or ripple effects this accommodation may create for other employees?

Assess precedent implications and communication strategy:

Environmental Health & Safety Director Name

EHS Director Review Date

EHS Risk Assessment - Evaluate potential hazards introduced by new equipment

Does the proposed equipment meet all workplace safety standards and certifications?

Identify safety certification gaps and required remediation:

I confirm that a workplace safety inspection will be conducted post-installation to verify compliance

Final Approval Decision

Detail conditions or modifications to original request:

Specify additional information required before decision:

Provide detailed rationale for denial and alternative solutions offered:

Final Decision Date

Implementation Plan and Timeline (if approved):

Is a post-implementation follow-up evaluation scheduled?

Follow-up evaluation date:

Explain why follow-up is not scheduled and how effectiveness will be monitored:

HR Business Partner Signature

EHS Director Signature

Employee Acknowledgment - I have reviewed the final decision and understand my rights to appeal if needed

Employee Signature