UMBC - Environmental Safety and Health

Ergonomic Survey Request Form

University of Maryland Baltimore County

This form will be forwarded to Injured Workers Insurance Fund (IWIF) / SERMA risk consultant who will contact you about this request and, if needed, schedule a site visit. Please allow 5-7 business days for response.

First Name*

Last Name*

Supervisor First Name*

Supervisor Last Name*

Email*

Workstation Description

Bldg of Survey*

Room No of Survey*

Discomfort Area (Check all which apply)*

Forearm

Hand

Head

Lower-back

Multiple

Neck

Other

Shoulders

Comments

Upload Dr.'s Note If Available

By clicking the submit button below I affirm the information provided above is accurate to the best of my knowledge. And I have read/reviewed this on-line ergonomic workstation tutorial found here