Occupational Ergonomics
Laboratory Task or
workstation Evaluation
Request Form
Personal Information
(Please fill out completely)
Full Name
Email
Phone Number
Job Title
Department
Lab. room or Office
Address
Reason for Request
(Answer
Yes
or
No
where appropriate)
New employee
New Workstation/or equipment
Experiencing Disconfort
Other
I am experiencing diconfort when performing the following tasks:
(Answer
Yes
or
No
where appropriate)
Pippeting
Microscopy
AT the workbench using a computer or other instrument
When using the Biosafety cabinet/fume hood
Other
(describe)
Type of Disconfort
(please describe your disconfort in few lines)
Environmental Health and Safety Office
URL:
http://www.d.umn.edu/ehso
13 Darland Administration Building
1049 University Drive
Duluth, MN 55812
218-726-7273
The University of Minnesota is an equal opportunity educator and employer.
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Last modified: February, 2009
