Comprehensive Evaluation for Workplace Accommodations & Ergonomic Solutions

1. Employee Profile & Workstation Location Metadata

Please provide accurate information to ensure efficient processing of your accommodation request. All fields marked as mandatory must be completed.


Employee ID

Full Legal Name

Department

Job Title/Role

Work Email Address

Phone Extension/Direct Line

Direct Manager/Supervisor Name

Employment Type

Original Hire Date

Primary Work Arrangement


Primary Workstation Building/Campus Name

Floor/Level

Zone/Wing/Area

Desk/Workstation Number

Describe Your Current Workstation Setup

How long have you been experiencing the current issue?

Rate the urgency of this request

2. Medical/Physician Certification & Physical Work Limitations

This section documents the medical necessity for accommodations. All information provided will be kept confidential and shared only with those involved in the accommodation process. A valid physician's certification is typically required for ergonomic and assistive technology requests.


Have you been formally diagnosed with a medical condition that affects your ability to perform job functions?


Do you have current physician certification (within the last 12 months) recommending workplace accommodations?


Date of Physician Certification

Nature of Medical Condition

Is this condition temporary or permanent?


Select all physical limitations that apply to your condition



Rate the severity of functional limitations in these key areas

No limitation

Mild limitation

Moderate limitation

Severe limitation

Unable to perform

Lifting or carrying objects

Repetitive hand/arm movements

Sustained sitting posture

Sustained standing posture

Viewing standard computer screens

Using standard keyboard/mouse

Concentrating for extended periods

Adapting to changes in routine

Maximum weight you can safely lift (in kg)

Maximum continuous sitting time without break (in minutes)

Maximum continuous standing time without break (in minutes)

Have you received workplace accommodations previously for this or any other condition?


Additional medical information or context HR should consider

3. Requested Assistive Hardware & Cost-Per-Item Breakdown

Provide detailed specifications for all requested equipment. Include cost estimates and vendor information. The HR team will verify pricing and manage procurement upon approval.


Accommodation Request Category

Detailed Equipment Request & Cost Breakdown

Item Name & Model

Vendor/Manufacturer

Quantity Required

Unit Cost (USD)

Total Cost

Justification & Specific Need

Product URL/Catalog Number

Adjustable Height Electric Desk - FlexiSpot E7
FlexiSpot
1
$499.99
$499.99
Required for alternating between sitting and standing due to chronic lower back pain
https://flexispot.com/e7-desk
Ergonomic Chair - Herman Miller Aeron
Herman Miller
1
$1,395.00
$1,395.00
Postural support for lumbar region; current chair causes pain after 20 minutes
https://hermanmiller.com/aeron
 
 
 
 
$0.00
 
 
 
 
 
 
$0.00
 
 
 
 
 
 
$0.00
 
 
 
 
 
 
$0.00
 
 
 
 
 
 
$0.00
 
 
 
 
 
 
$0.00
 
 
 
 
 
 
$0.00
 
 
 
 
 
 
$0.00
 
 

Total Estimated Cost for All Requested Items

Does the total cost exceed $1,000 USD?


Describe alternative solutions you have tried or considered

Rank these items by priority (1 = highest priority)

Primary workstation furniture (desk/chair)

Input devices (keyboard/mouse)

Visual display equipment (monitors/mounts)

Assistive software

Environmental controls

Mobility/accessibility modifications

Requested Implementation Date

Does this equipment require professional installation?


Will you require training to use this equipment effectively?


4. Workplace Physical/Virtual Ergonomic Audit Checklist

This section helps assess the current workstation setup and identify ergonomic risk factors. Please complete honestly and upload supporting photographs where applicable.


Upload current workstation photos (front view, side view, and problem areas)

Choose a file or drop it here

Rate the ergonomic condition of existing equipment

Office chair adjustability and support

Desk height and surface area

Monitor position and viewing angle

Keyboard and mouse placement

Lighting quality and glare control

Footrest availability

Document holder accessibility

Cable management and safety

Assess environmental comfort factors (1 = Very Poor, 5 = Excellent)

Overall lighting brightness

Screen visibility (no glare)

Ambient noise level

Temperature control

Air quality and ventilation

Privacy and focus ability

Accessibility of shared facilities

Which postural issues do you experience during work? (Select all that apply)

Do you experience pain or discomfort that worsens throughout the workday?


Which virtual/digital ergonomics factors need improvement? (Select all that apply)

How would you rate your current workflow efficiency given your limitations?

Describe any specific tasks that are difficult or impossible to perform with current setup

I confirm that the information provided in this audit accurately reflects my current workstation conditions

5. HR Business Partner & EHS Lead Clearance Sign-Off

This final section is to be completed by HR Business Partner and Environmental Health & Safety (EHS) Lead. It ensures proper review, risk assessment, and formal approval of the accommodation request.


HR Business Partner Name

EHS Lead Name

Review Date

Risk Assessment Matrix

Low Risk

Medium Risk

High Risk

Critical Risk

Medical documentation completeness

Accommodation reasonableness

Workplace safety impact

Budget feasibility

Implementation complexity

Employee privacy considerations

Legal compliance risk

Compliance Verification Checklist

Budget Approval Status


Approved Implementation Date

Conditions of Approval or Special Provisions

HR Business Partner Digital Signature

EHS Lead Digital Signature

Final Accommodation Decision

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