City Of Oakland
Ergonomics Program
Work Site Evaluation Request (E101)
Section 1 – Requestor Information
Agency/Department: ___________________
Date of Request:___________________
Contact Name: ________________________
Authorizing Signature: _________________
Phone Number: ___
Phone Number: __
__________
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Type of Evaluation: ___Computer Work Station Evaluation
Name of Employee: ___________________
Employee # ________________
______ Phone Number:____________________
__________
New Employee: New Equipment:
Specialty Workstation, Non-Industrial
Specialty Workstation, Industrial
Job Processes or Operations/Non-Computer Workstation
Construction/Renovation Designs
New Furniture/Equipment Design
_ Job/Task Safety Analysis
_ Job Physical Demand/Capacity Review
Other (please specify):____________________________________________________
________________________________________________________________________
Section 2 – Location and Description of Request
Address of Worksite:_______________________________________________________________
_________________________________
______________________________________
Usual Work Hours: ____ AM/PM to ___AM/PM Usual Workdays: M Tu W Th F Sa Su
Description of Work Site or Process:
Description of Problems, Complaints or Symptoms (if any):
INSTRUCTIONS:
1. Department staff completes Sections 1 and 2. Attach supplementary information as needed.
2. Obtain authorizing signature (supervisor or manager).
3. Forward form to Risk Management to
eturner@oaklandnet.com or fax to 238-4749.
If you have any questions, contact Greg Elliott at 238-4993 or Erika Turner at 238-7660.
Assigned to: _________________ Date Assigned:____________ Deadline:_______ Initials _______
Comments:________________________________________________________________________________
_____________________________________________________________________________________
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