UMB Environmental Health and Safety

Ergonomic Survey Request Form

This form will be forwarded to Injured Workers Insurance Fund (IWIF) / SERMA risk consultant who will contact you about this request and, if needed, schedule a site visit. Please allow 5-7 business days for repsonse.

Name:	First Last
Supervisor Name:	First Last
Date Submitted:
Date Selected for Survey:	i.e., (02/05/05)
Email:
Location of Survey:	Building Room
Workstation Description:
Discomfort Area:	head neck forearm hand shoulders lower back multiple (Check all which apply)
Comments:
EHS also recommends visiting the following OSHA website that delineates the proper ergonomic workstation setup. http://www.osha.gov/SLTC/etools/computerworkstations/index.html

home > osh home > ergonomic survey request form