Fillable HOME WORKSTATION REVIEW FORM (Hydro One)

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HOME WORKSTATION REVIEW FORM (Hydro One)

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H&W 2020 Page 1
HOME WORKSTATION REVIEW FORM
Date
1.
Employee
Information
Name
Employee No.
Current Job Title
Phone
Division
2.
Have you
reviewed the
following?
Ergonomic Tips for Setting Up Your Home Workstation
YES
NO
3.
Specify in
detail the
reason for
assessment
a) Describe specific workstation related issues/concerns. Include specific job related tasks to this request.
b) If experiencing any symptoms list body part(s).
4.
Manager’s
Approval
Obtained
_____________________________
Manager’s Name (Please Print)
___________________________
Phone Number
Please send the following to Health Services via email
(Health.Wellness@HydroOne.com
)
or fax (416-981-8737):
1) a picture of your current workstation
2) a picture of you working at your workstation
3) this completed form
Following receipt and review of the pictures and completed form you will be contacted
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HOME WORKSTATION REVIEW FORM (Hydro One)

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Completed 23 July 2021

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