Ergonomics Services Request Form

Managers and supervisors are responsible for conducting ergonomic evaluations for their employees as per P&P 290-16. 

Participation by the manager/supervisor is required in order to perform an ergonomic evaluation of the employee's workstation. Employees desiring an ergonomic evaluation will need to contact their supervisor.

If you work at the UC Davis Health System in Sacramento, please contact Michael Galang to request an ergonomic evaluation of your workstation:
mbgalang@ucdavis.edu
916-734-8840
Section A: Supervisor Information
Is the employee currently under medical care for a repetitive motion injury?
Has a workers' compensation claim been filed?
Has a Tier 1 Ergonomic Evaluation been performed?
Section B: Employee Information
Section C: Type of Ergonomic Service Requested
Please indicate which type of ergonomic service you are requesting:
Focused evaluation of workstation's components such as sit/stand or if an urgent visit is needed. Ergonomics Consultation will not have a follow up report. It is just a quick visit with a follow up email, if necessary.
Comprehensive evaluation of workstation. A Tier 1 Ergonomics Evaluation should have been completed by the Department Safety Coordinator (DSC) before it is escalated to a Tier 2.
To test keyboards, mice, sit/stand demos, and other office equipment. The equipment can be loaned to UC-Davis campus employees for a week to ensure the compatibility and fitness of the equipment before placing an order to purchase. For chair fitting, please contact Furniture Services at Furniture@ucdavis.edu.
Evaluation of any work process other than office environment.
Basic ergonomics for computer users.
Section D: Concern or Service Requested
Your Department Safety Coordinator's (DSC) Information
DSC lookup: http://safetyapps.ucdavis.edu/EHS/dsc/index.cfm
Your DSC will be emailed a copy of this request.