This section collects essential information about your employment status and current workstation arrangements across hybrid locations. Accurate details ensure proper evaluation and equipment allocation.
Employee Full Name
Employee ID Number
Department/Business Unit
Job Title/Role
Direct Manager Name
Official Company Email Address
Direct Contact Phone Number
Employment Classification
Full-Time Permanent
Part-Time Permanent
Full-Time Contract
Part-Time Contract
Intern/Apprentice
Consultant
Have you completed the company's mandatory ergonomic self-assessment training within the last 12 months?
Average weekly hours worked from office location
Average weekly hours worked from home location
Describe your primary work tasks and activities (e.g., typing, video conferencing, document review, design work)
Primary Office Location Address
Home Workstation Full Address
Do you have a dedicated, private room for your home office workstation?
Which equipment is currently provided by the company? (Select all that apply)
Office desk
Office chair
External monitor(s)
Keyboard
Mouse
Laptop stand
Docking station
Headset
Webcam
None of the above
Which equipment do you personally own and use for work? (Select all that apply)
Desk
Chair
Monitor(s)
Keyboard
Mouse
Laptop stand
Footrest
Document holder
Wrist rest
Other ergonomic accessories
Have you previously received ergonomic accommodations or adaptive equipment from this employer?
Are you currently experiencing pain or discomfort that you believe is work-related?
This section must be completed by a qualified medical practitioner. Upload certification documents and provide detailed pain assessment. All medical information will be handled with strict confidentiality per global data protection standards.
Certifying Medical Practitioner Full Name
Medical Practice/Clinic Name
Medical Practitioner License/Registration Number
Date of Medical Examination
Certification Valid Until Date
Upload official medical certification letter or report (PDF, JPG, PNG accepted)
Primary Medical Diagnosis or Condition Requiring Ergonomic Accommodation
Secondary or Related Conditions (if applicable)
Is this condition considered permanent or long-term (expected to last 12+ months)?
Rate the severity of symptoms experienced in the LAST 30 DAYS for each body region (0 = No Pain, 1 = Mild, 2 = Moderate, 3 = Severe, 4 = Very Severe)
0 - No Pain | 1 - Mild | 2 - Moderate | 3 - Severe | 4 - Very Severe | |
|---|---|---|---|---|---|
Neck/Cervical spine | |||||
Shoulders (Right) | |||||
Shoulders (Left) | |||||
Upper back/Thoracic spine | |||||
Lower back/Lumbar spine | |||||
Wrists/Hands (Right) | |||||
Wrists/Hands (Left) | |||||
Hips/Pelvis | |||||
Knees (Right) | |||||
Knees (Left) | |||||
Eyes/Vision strain | |||||
Headaches (frequency) |
Rate how much each symptom INTERFERES with your work performance (0 = No Interference, 1 = Slight, 2 = Moderate, 3 = Severe, 4 = Very Severe)
0 - No Interference | 1 - Slight | 2 - Moderate | 3 - Severe | 4 - Very Severe | |
|---|---|---|---|---|---|
Typing speed and accuracy | |||||
Ability to sit for extended periods | |||||
Concentration and focus | |||||
Participation in video meetings | |||||
Overall productivity | |||||
Sleep quality affecting work | |||||
Mood and stress levels |
When did symptoms first begin?
Less than 3 months ago
3-6 months ago
6-12 months ago
1-2 years ago
More than 2 years ago
Since childhood/congenital
Have symptoms worsened since beginning hybrid work arrangement?
Which work activities specifically aggravate your condition? (Select all that apply)
Prolonged sitting (>2 hours uninterrupted)
Repetitive typing/data entry
Mouse use/clicking
Looking up/down at monitor
Poor lighting causing eye strain
Inadequate back support
Wrist positioning on desk edge
Holding phone for calls
Reading documents flat on desk
None of the above
List all current medications or treatments for this condition
Have you tried any ergonomic interventions or equipment previously?
Medical practitioner's specific ergonomic recommendations (if any)
Detail each piece of specialized ergonomic furniture or adaptive hardware requested for both home and office locations. Provide justification, vendor details, and cost breakdown. Requests exceeding standard thresholds may require additional approval levels.
Detailed Equipment Request & Cost Analysis
Equipment Category | Specific Product Name/Model | Intended Location | Medical/Ergonomic Justification | Unit Cost | Quantity | Extended Cost | Preferred Vendor | Lead Time (weeks) | |
|---|---|---|---|---|---|---|---|---|---|
Ergonomic Office Chair | Global ErgoPro Max Adjustable | Home | Lumbar support for chronic lower back pain | $850.00 | 1 | $850.00 | ErgoSupplies International | 3 | |
Height Adjustable Desk | FlexiDesk Pro 120x80cm Electric | Home | Alternating sit/stand for cervical spine condition | $650.00 | 1 | $650.00 | Workplace Solutions Ltd | 2 | |
Monitor Arm | Dual Monitor FlexMount Pro | Office | Proper monitor positioning to reduce neck strain | $180.00 | 1 | $180.00 | TechMount Corp | 1 | |
Ergonomic Keyboard | Split Design K860 | Both | Wrist neutral positioning for RSI | $120.00 | 2 | $240.00 | Input Devices GmbH | 1 | |
Footrest | Adjustable ErgoFoot Pro | Home | Leg support for hip alignment | $45.00 | 1 | $45.00 | ErgoSupplies International | 1 | |
$0.00 | |||||||||
$0.00 | |||||||||
$0.00 | |||||||||
$0.00 | |||||||||
$0.00 |
Total Equipment Cost (Auto-Calculated)
Does this request exceed your department's standard ergonomic equipment budget threshold?
What is the expected duration of need for this equipment?
Permanent (employee's tenure)
Temporary (6-12 months recovery)
Trial period (3 months evaluation)
Project-based (specify duration)
Have you researched alternative or comparable products at lower price points?
Which compliance standards must the equipment meet? (Select all that apply)
ISO 9241-5 Ergonomic Requirements
BIFMA Standards
ANSI/HFES 100 Standards
EN 1335 Office Chair Standard
GREENGUARD Certification
No specific standards required
Other (specify in comments)
Additional notes on equipment specifications, delivery requirements, or installation needs
Conduct a self-assessment of your home workstation using the checklist below. Upload photos/videos showing current setup from multiple angles. This audit helps identify risks and verify equipment needs before approval.
Upload photo: Full workstation view (front angle showing desk, chair, monitor)
Upload photo: Side view showing monitor height relative to eye level
Upload photo: Seated position showing back support and feet placement
Upload photo: Keyboard and mouse positioning (close-up)
Upload photo: Room lighting and window positioning
What is the approximate room size (square meters/square feet)?
Current desk height (cm/inches)
Current monitor size (diagonal inches)
Distance from eyes to monitor screen (cm/inches)
Rate compliance with ergonomic best practices for each element
Non-Compliant | Partially Compliant | Fully Compliant | Exceeds Standard | |
|---|---|---|---|---|
Monitor top at or below eye level | ||||
Monitor directly in front (no twisting) | ||||
Chair provides adequate lumbar support | ||||
Feet flat on floor or footrest | ||||
Thighs parallel to floor | ||||
Wrists straight and neutral | ||||
Frequently used items within reach | ||||
Adequate lighting (no glare or shadows) | ||||
Adequate leg clearance under desk | ||||
Ability to alternate postures |
Are there any immediate safety hazards in your workspace? (e.g., loose cables, unstable furniture, poor ventilation)
Do you experience glare on your screen from windows or lighting?
How would you rate the overall ergonomic setup of your home workstation?
Poor - significant improvements needed
Fair - some improvements needed
Good - minor improvements needed
Excellent - meets all ergonomic standards
Is there sufficient space to accommodate the requested new equipment?
Additional observations about your home office environment not covered above
Final authorization section for HR and Health Safety stakeholders. All approvals required before procurement and delivery of ergonomic equipment.
HR Director Full Name
HR Director Title
HR Review Date
HR Approval Status
Approved - Proceed to procurement
Approved with conditions (see notes)
Deferred pending additional information
Rejected - does not meet criteria
HR Director Digital Signature
Health & Safety Officer Full Name
Health & Safety Officer Certification Number
Health Safety Review Date
Does the request align with occupational health and ergonomic safety standards?
Health & Safety Officer Digital Signature
Finance Budget Authority Name (if required)
Approved Budget Amount
Expected Equipment Delivery Date
Employee Training/Orientation Scheduled Date
Will equipment require professional installation or assembly?
Post-Implementation Review Schedule
30 days after delivery
60 days after delivery
90 days after delivery
6 months after delivery
12 months after delivery
As needed based on condition
Special conditions, notes, or additional stakeholders requiring notification
I acknowledge that all information provided is accurate and complete to the best of my knowledge