Public Schools of
San Luis Obispo County

Ergonomic Workstation Evaluation - Request Form

This form shall only be completed by the District Safety Coordinator, SIPE Board Member or designee.

Employees:

Employees desiring an ergonomic evaluation will need to contact their supervisor.

Supervisors:

Please send all evaluation requests to your District Safety Coordinator.

The evaluation will consist of an interview with the employee(s) to determine how effectively the workstation enables the performance of job duties/tasks. The evaluator will make recommendations regarding work processes and workstation equipment. Within about 2 working days of receipt, SIPE will contact the employee or department manager to schedule the evaluation. Please allow 20 - 45 minutes for individual appointments.

Required fields are denoted with *.

Section A: District Name

Section B: Select the Type of Ergonomic Service Requested*



Section C: Employee or Department Information

(The employee will receive a copy of this request.)

Section D: For Special Education or Departmental Training

Section E: Reason for Request

Section F: Complete for Computer Workstations Only

Does the employee have an adjustable ergonomic office chair?
Does the employee have an adjustable keyboard tray?
Does the employee have a sit-to-stand or standing workstation?
Has this employee been evaluated in the past?

Section G: Your Information

Important Note: Some school districts filter their emails for spam. Make sure your district's spam filter will accept email from safetyreport@slosipe.org.