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
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.
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