Workplace Adjustment Request
WORKPLACE ADJUSTMENT REQUEST
Please complete all sections of this request form.
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Employee Information |
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Name: |
[Name] |
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Job Title: |
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Department: |
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Contact Information: |
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Workplace Adjustment Request |
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Component |
Items |
Details |
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Nature of the Adjustment Request |
Ergonomic Concern: |
Desk is too high causing strain on the neck and back. |
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Health and Safety Implications: |
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Current Work Environment Description: |
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Recommendations for Adjustment |
Proposed Solutions: |
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Equipment or Furniture Modifications: |
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Workstation Layout Changes: |
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Supporting Documentation |
Medical Documentation: |
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Additional Evidence: |
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Previous Accommodations History: |
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Acknowledgement
I, [Name], hereby acknowledge that the information provided in this Workplace Adjustment Request is true and accurate to the best of my knowledge.
Signature:
[Name]
[Job Title]
Date: [MM/DD/YYYY]
Approval
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Approved
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Declined
Signature:
[Your Name]
[Job Title]
Date: [MM/DD/YYYY]
If you have any questions or concerns regarding this request or the decision made, please feel free to reach out to [Your Name] at [Your Email]. Your feedback is important to us.
