Montana State University

Safety and Risk Management
Montana State University
P.O. Box 170510
Bozeman, MT 59717-0510

Tel: (406) 994-2711
Fax: (406) 994-7040

Physical Address:
1160 Research Drive
Bozeman, MT 59718

Director:
Chris Catlett
(406) 994-4146
christopher.catlett@montana.edu

 

 

 

Ergonomic Assessment Request

Please complete this form to request an Ergonomics Evaluation. If you are not contacted within 5 business days, please contact the program manager at 994-7384 directly.

If your situation may be covered by the Americans with Disabilities Act, please contact MSU's ADA coordinator, Katarzyna Maison-Franklin, at 994-2629 or k.maisonfranklin@montana.edu.

Please fill out the form below
* Denotes a required field.

Prerequisites

* Yes     No

* Yes     No
* Yes     No
* Yes     No
* Yes     No Help

After making changes to your workstation, it is important to have time for your body to adjust to the changes. Please allow yourself two weeks, during which you can make additional minor changes to your set-up. After two weeks, if your pain persists, please submit this form to schedule an ergonomics evaluation.

My Information

*
*
*

My Supervisor's Information

*
*
*

Historical Information

* Yes     No Have you had an ergonomics evaluation at MSU before?
If so, when:
Describe the outcome of the evaluation:

Your Working Conditions

* Describe the pain/discomfort:
*What are you typically doing when you notice the pain/discomfort:
*What makes the pain/discomfort worse or better:
*What is the frequency of pain/discomfort:
*When did the pain/discomfort start?
* Yes     No Have you seen a medical professional to assist with the pain/discomfort?
(i.e. chiropractor, nurse, physician, physical therapist, etc.)
If so, what type:
The pain/discomfort is related to work activities
* Yes     No


Upon submittal, your request will be sent to the Ergonomics team at Safety & Risk,
your supervisor, and you will receive an email confirmation of your request.


   [ RESET FORM ]