Employment & HR

Ergonomics Self-Assessment & Request

Employee-completed ergonomics self-assessment for office and computer-based workstations, capturing discomfort symptoms, current workstation setup, and any accommodation or equipment requests. Supports employer OSHA general duty clause compliance and proactive musculoskeletal disorder (MSD) prevention.

📄 1 signer📅 30-day expiry🏷 Employment & HR🔖 ergonomics, workstation, safety, msd-prevention, accommodation, osha, hr, office-safety, remote-work

About this template

The Ergonomics Self-Assessment & Request is a ready-to-use employment & hr template you can send for signature in minutes. It is written for 1 signer (employee) and, by default, expires 30 days after it is sent if left unsigned. It covers ergonomics, workstation, safety, msd prevention, accommodation, osha. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.

Document Preview

# Ergonomics Self-Assessment & Request --- ## Employee Information **Employee Full Name:** ___________ **Employee ID:** ___________ **Department:** ___________ **Job Title:** ___________ **Supervisor Name:** ___________ **Work Location:** ___________ **Work Site Address (if remote, your home office address):** ___________ **Date of Assessment:** ___________ **Approximate hours per day at computer workstation:** ___________ --- ## Current Workstation Setup ### Seating **Chair type:** ___________ **Can your chair height be adjusted?** ___________ **Does your chair provide lumbar (lower back) support?** ___________ **Are your feet flat on the floor or a footrest when seated?** ___________ **Do you use a footrest?** ___________

Fields (59)

employee full name
text · required
employee id
text
department
text · required
job title
text · required
supervisor name
text · required
work location
select · required
work site address
textarea · required
assessment date
date · required
hours at workstation
select · required
chair type
select · required
chair adjustable
radio · required
chair lumbar
radio · required
feet flat
radio · required
footrest
radio · required
desk type
select · required
monitor count
select · required
monitor height
radio · required
monitor distance
select · required
laptop only
radio · required
keyboard type
select · required
keyboard height
radio · required
wrist rest
radio · required
mouse type
select · required
mouse level
radio · required
glare free
radio · required
eye strain
radio · required
lighting adequate
radio · required
symptom neck
select · required
symptom shoulders
select · required
symptom upper back
select · required
symptom lower back
select · required
symptom elbows
select · required
symptom wrists
select · required
symptom hips
select · required
symptom knees
select · required
symptom eyes
select · required
symptom timing
select · required
symptoms affect life
radio · required
medical treatment
radio · required
symptom notes
textarea
has request
radio · required
request chair
checkbox
request monitor arm
checkbox
request sit stand
checkbox
request keyboard
checkbox
request mouse
checkbox
request wrist rest
checkbox
request footrest
checkbox
request laptop stand
checkbox
request headset
checkbox
request lighting
checkbox
request document holder
checkbox
request other
checkbox
request details
textarea
ada related
radio · required
request urgency
select · required
break frequency
select · required
twenty rule
radio · required
stretches
radio · required

Related Employment & HR templates

ESPP Enrollment & Payroll Deduction Authorization
Exit Interview & Separation Checklist Acknowledgment
Flexible / Alternate Work Schedule Agreement
Flexible Spending Account (FSA) Election
FMLA Leave Request & Designation
Harassment Investigation Participation Consent

All 96 Employment & HR templates →  ·  Browse all templates →

Send this template with cryptographic proof

Every signed document gets PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package sealed in WORM storage.

Try the DemoView PricingFounding Member — 50% Off