Comprehensive Assessment for Specialized Ergonomic Furniture & Adaptive Hardware Requests

Employee Full Legal Name

Employee Identification Number

Official Job Title

Primary Department/Division

Direct Manager Name

Work Email Address

Direct Contact Phone Number

What is your primary work location arrangement?

Office Building Name & Floor Number

Describe your dedicated home office space (room type, privacy level, door availability)

Provide details for BOTH office location (building/floor/desk) AND home workspace description

Provide co-working space name, address, and membership details

Describe typical work environments and frequency of desk usage

Computer Operating System & Version

Inventory of Current Workstation Equipment Provided by Employer

Have you previously received any ergonomic accommodations from this employer?

Describe previous accommodations, dates provided, and outcomes

How many years have you been in your current role?

Employment Status

Describe your typical daily work pattern and hours spent at workstation

Do you experience pain or discomfort while performing your job duties?

Detail specific tasks, body parts affected, pain frequency (daily/weekly), and severity (scale 1-10)

Primary Diagnosing Healthcare Professional's Full Name

Healthcare Professional's Official Title & Specialization

Healthcare Provider Institution/Practice Name

Date of Medical Evaluation

Medical Certification Expiration Date (if applicable)

Primary Medical Condition Category

Select all affected anatomical regions

Select all neurological symptoms

Select visual accommodation needs

Rate the severity of functional limitations in these key areas (as certified by healthcare provider)

Prognosis & Expected Duration of Condition

Expected Recovery Date

Describe expected progression timeline and anticipated future accommodation needs

Healthcare Provider's Specific Recommendations for Workplace Accommodations

Does the medical certification indicate that failure to provide accommodations may result in further injury or permanent impairment?

Summarize the medical risk statement from provider

Is a follow-up medical reassessment required?

Scheduled Reassessment Date

Upload Official Medical Certification Document (must be on provider letterhead, signed, and dated within last 90 days)

Upload Photo of Healthcare Provider's Business Card (for verification purposes)

Primary Equipment Category Requested

Detailed Itemized Equipment Request & Cost Analysis

Grand Total Investment (All Items Combined)

Does this request exceed your department's pre-approved accommodation budget threshold?

Provide executive-level business justification for exceeding standard budget

Describe Alternative Solutions You Researched and Why They Were Deemed Insufficient

Will this equipment require specialized IT support or software installation?

Detail IT requirements, compatibility checks, and support plan

Expected Timeline for Measurable Improvement in Job Performance & Comfort

Define Success Metrics: How will you measure if this accommodation is effective?

Upload Product Specification Sheets or Web Links (PDF format preferred)

Is this equipment request time-sensitive due to medical urgency?

Explain urgency and provide any supporting medical documentation referencing time-critical need

Audit Conducted By

Auditor's Full Name & Credential

Audit Date & Start Time

Was the audit conducted on-site at the employee's primary workstation?

Describe remote/virtual audit methodology (video call, photos submitted, self-reported measurements)

Objective Workstation Measurements & Environmental Data

Postural & Behavioral Risk Assessment (Auditor Observation & Employee Self-Report)

Select All Equipment Deficiencies Identified During Audit

Are there immediate, low-cost corrective actions that can be implemented before major equipment arrives?

List interim solutions (e.g., monitor riser blocks, temporary footrest, repositioning, software reminders)

Upload Minimum 8 Photos: Workstation Front View, Side View, Keyboard/Mouse Position, Seated Posture, Monitor View, Under-Desk Area, Lighting Source, Overall Room Layout

Upload Video Recording (2-3 min) Demonstrating Employee's Typical Work Tasks and Movements (optional but recommended)

Auditor's Comprehensive Risk Summary & Justification for Requested Equipment

Overall Workstation Ergonomic Risk Score (1=Compliant, 5=Immediate Intervention Required)

HR Business Partner Full Name

HR Business Partner Employee ID

HRBP Review Date & Time

Health & Safety Lead Full Name

Health & Safety Lead Credential/Registration Number

Health & Safety Review Date & Time

Risk & Compliance Assessment by Approving Authorities

Has a formal interactive process meeting been conducted with the employee to discuss request and alternatives?

Interactive Process Meeting Date

Summary of Interactive Process Discussion & Employee Input on Alternative Solutions

Final Accommodation Decision

Detailed Decision Rationale & Conditions

Does this approval require executive-level budget authorization beyond standard HRBP authority?

Executive Approver Name & Title

Targeted Equipment Delivery/Installation Date

Mandatory Follow-Up Reassessment Date (30-90 days post-implementation)

I confirm that all procurement will comply with company asset management policies and equipment will be tagged and inventoried

I acknowledge that this accommodation is provided exclusively for the requesting employee's documented medical need and is not transferable

I verify that the interactive process has been documented and all communications are retained in the employee's confidential medical file

HR Business Partner Digital Signature

Health & Safety Lead Digital Signature