Title Page
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Document No.
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Office of Health and Safety Ergonomic Equipment Refusal Form Procedure
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Employee / Unit
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Conducted on
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Prepared by
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Location
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Personnel
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Type of ergonomic equipment or training refused by employee:
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Head set
- Compliant
- Employee refuses to use this item
- The equipment is not available at the employee's work station
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Corner bracket
- Compliant
- Employee refuses to use this item
- The equipment is not available at the employee's work station
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Adjustable chair
- Compliant
- Employee refuses to use this item
- The equipment is not available at the employee's work station
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Adjustable stool
- Compliant
- Employee refuses to use this item
- The equipment is not available at the employee's work station
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Adjustable foot rest
- Compliant
- Employee refuses to use this item
- The equipment is not available at the employee's work station
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Adjustable foot machine
- Compliant
- Employee refuses to use this item
- The equipment is not available at the employee's work station
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Adjustable monitor arm
- Compliant
- Employee refuses to use this item
- The equipment is not available at the employee's work station
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Adjustable keyboard tray
- Compliant
- Employee refuses to use this item
- The equipment is not available at the employee's work station
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Adjustable mouse tray
- Compliant
- Employee refuses to use this item
- The equipment is not available at the employee's work station
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Adjustable copy drawer/document holder
- Compliant
- Employee refuses to use this item
- The equipment is not available at the employee's work station
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Ergonomics Training
- Compliant
- Employee refuses to use this item
- The equipment is not available at the employee's work station
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Other
- Compliant
- Employee refuses to use this item
- The equipment is not available at the employee's work station
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Acknowledgement: I understand that the goal of MVC ergonomics program is to reduce musculoskeletal stresses associated with a job or task including the risk of carpal tunnel syndrome associated with improper wrist extension. I acknowledge that by refusing to use the ergonomic equipment as instructed may result in denial of claims. I authorize the MVC to forward a copy of this form to Risk Management, Department of Treasury for any related Worker's Compensation claims.
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Note: A copy of this signed form will be placed in your medical file. Failure to sign this form does not relieve an employee of the responsibility to understand and adhere to the standards of ergonomic equipment and training.
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If you have any questions regarding this matter or need additional information, please do not hesitate to contact the Office of Health and Safety.
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Employee's Signature
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Evaluator's Signature
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Manager's Signature
