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

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

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

Comments

If you are human, leave this field blank.

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Ergonomics Service Request Form