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Workstation Evaluation Request Form
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Today's Date
MM slash DD slash YYYY
Site
Employee Name
First
Last
Title
Contact number
Email
Did you complete the Ergonomics in the Workplace Course and receive a certificate?
No
Yes
Course must be completed before proceeding
Primary reason for request?
Direct Supervisor Name
First
Last
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Have you notified you supervisor that you submitted this request?
No
Yes
Supervisor must be notified before submitting the form
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