Employee Ergonomic Assessment Request (Healthcare)

Employee Ergonomic Assessment Request (Healthcare) — Form Fields

This healthcare template includes 8 fields. Allow healthcare staff to request an ergonomic assessment of their workstation or patient care environment. Free to customize and use on ZenBuild.

• Employee Name (text, required)
• Work Email (email, required)
• Job Title (text, required)
• Department or Unit (text, required)
• Work Environment (dropdown selection, required) — options: Nursing station, Administrative office, Laboratory, Patient room, Procedure room, Other
• Current Concerns (checkboxes, required) — options: Neck or back pain, Wrist or hand discomfort, Eye strain from screens, Awkward patient handling positions, Repetitive motion concerns, Other
• Describe your workspace and the concern (long text, required)
• Urgency (multiple choice, required) — options: Routine, Elevated - worsening discomfort, Urgent - affecting work performance