WORKPLACE ADJUSTMENT REQUEST

Please complete all sections of this request form.

Employee Information
Name:	[Name]
Job Title:
Department:
Contact Information:

Workplace Adjustment Request
Component	Items	Details
Nature of the Adjustment Request	Ergonomic Concern:	Desk is too high causing strain on the neck and back.
	Health and Safety Implications:
	Current Work Environment Description:
Recommendations for Adjustment	Proposed Solutions:
	Equipment or Furniture Modifications:
	Workstation Layout Changes:
Supporting Documentation	Medical Documentation:
	Additional Evidence:
	Previous Accommodations History:

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

• Approved

• 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.

Health & Safety Templates @ Template.net