Workplace Ergonomics Complaint Form

Workplace Ergonomics Complaint Form — Form Fields

This operations template includes 10 fields. Allow employees to report ergonomic discomfort or injury risks at their workstation and request an assessment. Free to customize and use on ZenBuild.

• Employee Name (text, required)
• Employee Email (email, required)
• Department (dropdown selection, required) — options: Engineering, Sales, Operations, HR, Finance, Marketing, Legal, Other
• Workstation Location (text, required)
• Type of Discomfort (dropdown selection, required) — options: Neck/Upper Back, Lower Back, Wrists/Hands, Shoulders, Eyes/Vision, Hips/Legs, Multiple Areas
• Description of Discomfort or Issue (long text, required)
• How Long Has This Been a Problem? (dropdown selection, required) — options: Less Than a Week, 1–2 Weeks, 1 Month, Over a Month
• Equipment Contributing to Issue (checkboxes, optional) — options: Chair, Monitor Height, Keyboard Placement, Mouse, Desk Height, Lighting, Footrest Needed
• Has This Caused You to Miss Work? (multiple choice, required) — options: Yes, No
• Proposed Adjustments Needed (long text, optional)