Ergonomic Worksite Analysis Request Form - Employer



Select Evaluation Type

Initial Ergonomics Screen (IES):

Our Initial Ergonomics Screens are designed to be done quickly and effectively to target individuals or departments in a timely manner (30-40 minutes each). We recommend this service when employees have no known symptoms and you want to ensure proper workstation set up. Some other reasons for our IES: as a follow up to a prior preventive eval; when new furniture or equipment has been provided; or your employee is a “new hire” and you want to assure good workstation ergonomics.


Our Level I Evaluation

Our Level I Evaluation is designed to help employees with early symptoms of discomfort but no claims have been reported. Our LEVEL 1 Service is designed to evaluate individuals quickly and effectively in 45-60 minutes using a 15 point objective ergonomic assessment that identifies and targets each employee’s specific needs. A typed summary of recommendations is provided upon completion.


Ergonomic Chair Fitting Evaluation

Ergonomic Chair Fitting Evaluation: Aside from the computer, the ergonomic chair is the most important tool in the office contributing to your employee's productivity. Our onsite chair fitting service helps you identify if your employee's current chair is the right fit or a misfit; if it is being used properly to minimize discomfort; offers the quality and competency to remain on the work floor to assure safe ongoing use. Our service will advise if you should keep, repair or replace the chair in a timely manner. If the chair needs to be replaced, we will measure your employee for best fit needed for a new chair. We can select from your chair standards or identify a chair from an outside source that will meet your employee's stature, comfort and work practice needs. This evaluation includes the onsite analysis of the chair; chair education on features/function and best fit; measurements and recommendations for a new chair in a comprehensive report.
Includes vendor quote on request. Onsite time: 30 minutes


Our Non-Occupational Medical EWA service

Non‐occupational Medical Ergonomic Worksite Analysis WI’s Non‐Occupational Medical EWA service can be prescribed by an employee’s physician or requested directly by the employer to assist with accommodating an individual with a diagnosed medical condition (no workers’ compensation claim). We utilize the same features found in the Preventive EWA but offer more detail specific to minimizing aggravation of the medical condition while supporting the employee in achieving the essential functions with reasonable accommodations. This evaluation is a preventive approach to FEHA/ADA and FMLA needs where there are no legal or performance factors involved.
Onsite time: Approximately 2 hours


Match Job Function to Ability

This onsite function‐ matching service combines ergonomic analysis, job analysis and physical demands with onsite testing of an employee’s abilities and limitations to match them to their current job’s essential functions. Various tasks from the job that require exertion are objectively tested to determine whether employee passes or the task needs modification. Our analysis and report takes the guess work out of whether the employee can perform the task with or without an accommodation for the purpose of RTW, modified or otherwise. Physician must release employee to RTW for this analysis and onsite testing.
Onsite time: Approximately 4 hours; 2 visits recommended


Job Analysis/Physical Demands

Our Job Analysis is an investigative tool that involves interviewing and observing an individual (injured worker) and/or co‐workers actually perform the job. We document the essential functions, evaluate to what extent and how the work is done focusing on time and effort required. We assess the physical, sensory and cognitive/mental demands of the job, tools and materials handled in the environment performed. We document objectively using time allocation units and force/repetition requirements so that the employer, physician and insurer can determine whether the employee is fit to return to work or requires accommodation. This document assists with creating appropriate modified duty and transitioning the injured worker back to full duty.
Onsite time: 2‐3 hours per job analysis


Home Office Evalution

Our Home Office Evaluation is appropriate for healthy or injured employees who work from home. We conduct a detailed analysis of the home office ergonomics and functional issues required of the job. This report assists the all parties involved to determine appropriate furniture and equipment needed as well as safe work practices in the home office.
Onsite time: 1.5‐2 hours


ADA Reasonable Accommodation (RA) Assessment (Interactive Process)

Our ADA RA Assessment is fully compliant with FEHA/ADA and the EEOC’s criteria in performing the interactive process with your employee when a reasonable accommodation is needed. Whether it is for a permanent workers’ compensation injury or other medical condition or disability, this service is the best option to identify the most appropriate reasonable accommodations for a successful RTW. We work with all parties involved in the case to identify the solutions that support accommodation. We utilize our functional limitations report, ergonomic analysis, job analysis and functional job matching assessment tools to create the ADA RA Assessment report. Our legally defensible process minimizes litigation and costs for the employer while assuring a successful outcome.
Onsite time: 2‐3 hours


Follow Up Visit (to prior eval)

Our Follow Up visit assures the employer, employee, physician and insurer that the initial evaluation (preventive, MO (WC), Indemnity (WC) or other assessment was implemented to the extent feasible to achieve the expected outcomes. We review the recommendations to validate implementation, assure correct set up of all tools and educate the employee on proper use of new products provided to support SAW/RTW. We provide a report of findings and any additional recommendations to support closure of the case.
Onsite time: 1‐2 hours



1 employee

Multiple Employees


Ergonomic Worksite Analysis: PDF form



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Other Employer Services

Wellness Initiatives (on-site stretching programs)
Injury Prevention Services
Home Office Evaluation
Initial Ergonomics Screen (30 minutes)
Level I Preventive Evaluation (45 minutes)
Workers’ Compensation Services
Disability Management (ADA)
Employee and Management Training Programs
Licenses, Software and Other Products
Customized
See more in the Services Page