Title Page
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Document No.
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Office of Health and Safety Ergonomic Equipment/Training Declination Form
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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 and/or training declined by employee:
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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 platform
- 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 rocker
- 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 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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Telephone head set
- 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 the Motor Vehicle Commission (MVC) ergonomics program is to reduce musculoskeletal stresses associated with a job or task. This includes, and is not limited to, carpal tunnel syndrome associated with improper wrist extension and neck, back, and leg pain associated with improper body posture. I acknowledge that by declining to use the ergonomic equipment as instructed may result in denial of any Workers' Compensation claims. I authorize the MVC to forward a copy of this form to the NJ Department of Treasury, Division of Risk Management, for any related Workers' Compensation claims.
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Note: A copy of this signed form will be placed in your medical file. Declining 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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Please call the MVC Office of Health and Safety (609-292-5258) to discuss this report or if we can provide any additional assistance.
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Employee's Signature
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Evaluator's Signature
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Manager's Signature
