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Ergonomics Service Request Form
Ergonomic Services Request Form
Please complete the following information and submit your request for ergonomic assistance AFTER obtaining authorization from your supervisor/manager.
Are you an Ann Arbor Campus or Medical school employee?
*
Yes
No
EHS does not provide service to you. Please click this
link
for Safety Management Services
Are you currently under a doctor's care or therapy for your ergonomic discomfort?
*
Yes
No
EHS does not provide service to you. Please click this
link
for MHealthy Medical Ergonomics
Employee Name
*
Date
Email
*
UMID
*
Job Title
*
Building
*
Room Number
*
Department
*
Work Phone
*
Cell Phone
Campus Address
*
Supervisor
Supervisor's Email
Supervisor's Phone
Checkboxes
New workstation
Discomfort, please list in comment field
Group training
Sit to stand office consultation
Other, see comments below
Comments
If you are human, leave this field blank.
Submit
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