This section captures essential employee identification and current workstation context to establish baseline conditions and logistical requirements for accommodation implementation.
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?
Fully On-Site (Company Office)
Fully Remote (Home-Based)
Hybrid (Combination of Office & Remote)
Co-working Space (Third-Party Location)
Mobile/Field-Based with Occasional Desk Use
Computer Operating System & Version
Inventory of Current Workstation Equipment Provided by Employer
Have you previously received any ergonomic accommodations from this employer?
How many years have you been in your current role?
Employment Status
Full-Time Permanent
Full-Time Contract/Temporary
Part-Time Permanent
Part-Time Contract/Temporary
Intern/Apprentice
Describe your typical daily work pattern and hours spent at workstation
Do you experience pain or discomfort while performing your job duties?
This section establishes the medical basis for accommodation requests. All information must be supported by documentation from a qualified healthcare professional. Incomplete or outdated certifications will delay processing.
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
Musculoskeletal Disorder (e.g., back, neck, joint issues)
Neurological Condition (e.g., nerve compression, tremor)
Visual Impairment (e.g., low vision, eye strain)
Upper Extremity Disorder (e.g., carpal tunnel, tendonitis)
Lower Extremity Disorder (e.g., circulation, mobility)
Chronic Pain Syndrome
Other Physical Disability
Rate the severity of functional limitations in these key areas (as certified by healthcare provider)
No Limitation | Mild (10-25% reduction) | Moderate (26-50% reduction) | Severe (51-75% reduction) | Complete Inability | |
|---|---|---|---|---|---|
Sitting tolerance (continuous duration) | |||||
Repetitive hand/arm movements | |||||
Neck rotation/flexion | |||||
Visual focus on screens | |||||
Fine motor control (typing, mouse use) | |||||
Lifting/carrying capacity | |||||
Standing tolerance | |||||
Concentration despite pain/discomfort |
Prognosis & Expected Duration of Condition
Temporary (less than 6 months)
Short-Term (6-12 months)
Long-Term (1-3 years)
Permanent/Stable
Progressive/Degenerative
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?
Is a follow-up medical reassessment required?
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)
Detail all requested equipment with comprehensive justification. Include product specifications, vendor details, and total cost of ownership. Requests without adequate justification or cost transparency may be delayed or denied.
Primary Equipment Category Requested
Seating Solutions
Height-Adjustable Work Surfaces
Input Devices (Keyboard/Mouse)
Monitor & Display Solutions
Assistive Technology Software
Environmental Controls
Document Handling Accessories
Lower Extremity Support
Other Specialized Equipment
Detailed Itemized Equipment Request & Cost Analysis
Item Description | Manufacturer & Model Number | Vendor/Supplier Name | Unit Price | Quantity | Extended Price | Shipping & Handling | Installation/Setup Fee | Training Cost (if applicable) | Annual Maintenance/Warranty | Total 3-Year Cost | Medical/Functional Justification | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
Ergonomic Office Chair with Lumbar Pump | Steelcase Gesture Chair | OfficePro Solutions | $1,249.99 | 1 | $1,249.99 | $125.00 | $75.00 | $0.00 | $89.99 | $1,719.96 | Prescribed for chronic L4-L5 disc herniation requiring dynamic lumbar support and arm adjustability for nerve pain reduction | |
Electric Sit-Stand Desk Base | Uplift V2 Commercial Frame | HumanCentric Office | $649.00 | 1 | $649.00 | $95.00 | $150.00 | $0.00 | $0.00 | $894.00 | Required for positional changes every 30-45 minutes per medical advice to reduce static load on lumbar spine | |
Vertical Ergonomic Mouse | Logitech MX Vertical | TechAccessories Direct | $99.99 | 1 | $99.99 | $12.50 | $0.00 | $0.00 | $0.00 | $112.49 | Reduces ulnar deviation and wrist pronation for carpal tunnel syndrome management | |
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Grand Total Investment (All Items Combined)
Does this request exceed your department's pre-approved accommodation budget threshold?
Describe Alternative Solutions You Researched and Why They Were Deemed Insufficient
Will this equipment require specialized IT support or software installation?
Expected Timeline for Measurable Improvement in Job Performance & Comfort
Immediate (within 1 week)
Short-term (2-4 weeks)
Medium-term (1-3 months)
Long-term (3-6 months)
Gradual/Progressive (6+ months)
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?
A comprehensive ergonomic audit must be completed by a qualified assessor (HR Ergonomic Specialist, Health & Safety Officer, or external certified consultant) before final approval. This section documents objective workstation measurements and risk assessments.
Audit Conducted By
Internal HR Ergonomic Specialist
Health & Safety Department Representative
External Certified Ergonomist
Remote Virtual Assessment via Video
Third-Party Occupational Health Provider
Auditor's Full Name & Credential
Audit Date & Start Time
Was the audit conducted on-site at the employee's primary workstation?
Objective Workstation Measurements & Environmental Data
Measurement Parameter | Current Status/Observation | Measured Value (inches/cm/lux/dB) | Industry Standard Range | Risk Level (1=Low, 5=Critical) | Notes & Deviations | |
|---|---|---|---|---|---|---|
Desk Height (floor to top surface) | Fixed non-adjustable desk | 29 | 22-28 inches (adjustable preferred) | Desk 1 inch above recommended max for employee height 5'4" | ||
Monitor Distance (eye to screen) | Too far due to deep desk | 28 | 20-26 inches | Causes forward head posture, neck strain | ||
Monitor Top Height (from floor) | Too high, no adjustment | 52 | Eye level or slightly below (48-50 inches for this employee) | Forces upward gaze, compresses cervical vertebrae | ||
Ambient Lighting (lux measurement) | Overhead fluorescent | 450 | 300-500 lux (no glare) | Acceptable level but light source causes screen glare | ||
Background Noise Level (dB) | Open office environment | 58 | 35-45 dB for concentrated work | Elevated noise increases muscle tension and stress | ||
Chair Seat Height (floor to pan) | Non-adjustable chair | 18.5 | 15-22 inches (adjustable) | Too high, feet cannot rest flat on floor | ||
Postural & Behavioral Risk Assessment (Auditor Observation & Employee Self-Report)
No Risk Observed | Minimal Risk (intermittent) | Moderate Risk (frequent) | High Risk (constant) | Critical Risk (immediate injury risk) | |
|---|---|---|---|---|---|
Forward head posture (monitor positioning) | |||||
Rounded shoulders (keyboard/mouse reach) | |||||
Wrist extension/deviation during typing | |||||
Lumbar lordosis loss (chair support) | |||||
Lower extremity circulation (seat pan depth) | |||||
Eye strain/blinking frequency | |||||
Static posture duration without movement | |||||
Awkward neck/trunk twisting |
Select All Equipment Deficiencies Identified During Audit
No adjustable chair lumbar support
Non-height-adjustable desk
Monitor lacks height/tilt adjustment
No keyboard tray or negative tilt
Mouse is non-ergonomic design
Inadequate footrest (or none)
No document holder for reference materials
Glare on screen from lighting/windows
Cables create obstruction/tripping hazard
Insufficient leg clearance under desk
No armrests or non-adjustable armrests
Keyboard/mouse at wrong height/angle
Are there immediate, low-cost corrective actions that can be implemented before major equipment arrives?
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)
Final authorization requires collaborative review by HR Business Partner and Health & Safety Lead. This section documents the interactive process, risk-based decision rationale, and compliance verification before procurement.
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
Fully Compliant/Low Risk | Minor Concerns/Manageable Risk | Moderate Concerns/Moderate Risk | Significant Concerns/High Risk | Non-Compliant/Critical Risk | |
|---|---|---|---|---|---|
Medical documentation completeness & validity | |||||
Equipment alignment with medical recommendations | |||||
Cost reasonableness vs. alternatives explored | |||||
Legal compliance with health & safety obligations | |||||
Business operational impact if denied | |||||
Interactive process adequacy (employee consultation) | |||||
Alternative accommodation feasibility | |||||
Timeline appropriateness given medical urgency |
Has a formal interactive process meeting been conducted with the employee to discuss request and alternatives?
Summary of Interactive Process Discussion & Employee Input on Alternative Solutions
Final Accommodation Decision
Full Approval (All Requested Items)
Partial Approval (Selected Items Only)
Conditional Approval (With Modifications)
Deferred Pending Additional Information
Alternative Accommodation Offered
Denial (With Rationale)
Detailed Decision Rationale & Conditions
Does this approval require executive-level budget authorization beyond standard HRBP authority?
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