Occupational Health and Wellness
Ergonomic Assessment Request
*Please return by fax to 519-780-1796
Or by email to ohw@uoguelph.ca
Employment Information
Full Name:
Position Title and Role Summary:
Department:
Bargaining Group:
Office Location:
Telephone #
Supervisor Name:
Supervisor Email:
Supervisor Extension:
Ergonomic Assessment Request. Please indicate reason for assessment below
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Signatures
Requested By:
Printed
Signature
Date
Supervisor
Printed
Signature
Date
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signature
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click to sign
signature
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