Fillable Ergonomic Assessment & Supplies Request Form (West Los Angeles College)

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Ergonomic Assessment & Supplies Request Form (West Los Angeles College)

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The Ergonomic Assessment & Supplies Request Form (West Los Angeles College) form is 1 page long and contains:

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  • 15 other fields

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File type: PDF

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Ergonomic Assessment & Supplies Request Form
Date:
Requester (print name):
Last:
First:
Full Time
Part Time Job Title:________________________________
Employee#: _____________
Best Phone Number:
Department:
Building/Office Rm. Number:
STOP HERE!
BELOW FOR OFFICE USE ONLY.
Recommended Equipment (to be completed by ergonomics assessor)
Ergonomic Chair
Footrest
Gel Wrist Rest for Keyboard
Lumbar Support Pillow
Anti-Glare Monitor Screen
Gel Wrist Rest for Mouse
Seat Cushion
Wireless Keyboard/Mouse Combo
Wireless Headset
Standing Desk & Anti-fatigue Mat
Other:
Other:
Printed Name:
Date:
Signature:
Authorized:
Approved:
Ergonomics Assessor (print)
VP Administrative Services (print)
Email:
Please allow up to four (4) weeks to process your request.
Employee Agreement
*TO BE SIGNED AT TIME OF PICK-UP OR DELIVERY*
I, the undersigned, acknowledge receipt of the equipment designated above. I also agree not to loan, transfer,
give possession of, misuse, modify or alter the above equipment. Whenever an item is no longer needed I will return
it
to Plant Facilities Office, Building A15, 6am-2:30pm Mondays thru Fridays
Ergonomics Assessor (Sign / Date)
VP Administrative Services (Sign / Date)
/
/
An Accredited California Community College
Administrative Services
9000 Overland Avenue, Culver City, CA 90230 / (310) 287-4368 | www.wlac.edu
An Accredited California Community College
Administrative Services
9000 Overland Avenue, Culver City, CA 90230 / (310) 287-4368 | www.wlac.edu
Instructions
1. Complete the top portion of the form with your contact information.
2. Email completed form to the Ergonomics Assessor, Hansel Tsai - tsaih@wlac.edu
3. Schedule your assessment.
4. Plant Facilities will deliver your approved equipment.
Please allow up to four weeks to process your request. Incomplete forms will delay processing.
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Ergonomic Assessment & Supplies Request Form (West Los Angeles College)

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Completed 6 September 2020

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