Office Ergonomics Assessment Request

Office Ergonomics Assessment Request — Form Fields

This business template includes 9 fields. Request an ergonomics assessment of an employee's workstation to prevent injury and improve comfort. Free to customize and use on ZenBuild.

• Employee Name (text, required)
• Employee Email (email, required)
• Department (text, required)
• Office Location or Floor (text, required)
• Work Setup (multiple choice, required) — options: In-office only, Hybrid, Remote only
• Current Discomfort Areas (checkboxes, optional) — options: Neck/shoulders, Back, Wrists/hands, Eyes, Hips/legs, Headaches
• Description of Current Setup (long text, optional)
• Primary Concern (dropdown selection, required) — options: Pain or discomfort, Preventive setup review, New workstation, Post-injury return
• Photo of Current Workstation (file upload, optional)