Ergonomic Review Request

Ergonomic Review Request — Form Fields

This operations template includes 9 fields. Request an ergonomic assessment of a workstation to identify risks and recommend improvements. Free to customize and use on ZenBuild.

• Employee Name (text, required)
• Email Address (email, required)
• Department (text, required)
• Workstation Location (text, required)
• Work Type (dropdown selection, required) — options: Office/Desk, Manufacturing/Assembly, Warehouse, Laboratory, Customer-Facing
• Reported Symptoms (checkboxes, optional) — options: Neck Pain, Back Pain, Shoulder Pain, Wrist/Hand Pain, Eye Strain, Fatigue, None
• Priority (dropdown selection, required) — options: Routine, Following Injury, New Employee Setup, Return from Leave, New Equipment
• Description of Concern (long text, required)
• Existing Equipment Adjustment Attempted? (multiple choice, required) — options: Yes, No