Request for Work Station Evaluation
This request must be initiated & signed by the Employees Supervisor
Please forward this completed form to kathleen_casey@cuesta.edu.
Supervisor Name: _______________________________ Extension: ______
Employee Name: __________________________ Room Number: ______ Extension: _____
Please check all of the items that are currently available at the employees work station:
Adjustable Chair
Keyboard Tray
Why is a Work Station Evaluation being requested?
Supervisor Signature: __________________________________________
After the completed form is received the employee will be contacted to coordinate a date and
time for the evaluation.
The Safety Compliance Coordinator will contact the Supervisor and Employee with the results
and any recommendations.
If you have any questions please contact the Safety Compliance Coordinator at Ext #3283