Workplace Accommodation Request: Comprehensive Ergonomic & Assistive Technology Evaluation

Employee Full Legal 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

Employment Classification

Primary Work Arrangement

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?

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?

Detailed Description of Work-Related Activities That Aggravate Symptoms:

Has the employee been prescribed physical therapy or rehabilitation?

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

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

Categories of Specialized Equipment Requested (select all applicable)

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

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

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

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

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

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?

Environmental Factor Assessment - Rate current workstation conditions

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

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

Will the accommodation affect adjacent workstations or shared workspace configurations?

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)?

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?

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

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

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?

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

Final Approval Decision

Final Decision Date

Implementation Plan and Timeline (if approved):

Is a post-implementation follow-up evaluation scheduled?

HR Business Partner Digital Signature

EHS Director Digital Signature

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