Title Page

  • Document No.

  • Office of Health and Safety Ergonomic Equipment/Training Declination Form

  • Employee / Unit

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • Type of ergonomic equipment and/or training declined by employee:

  • Adjustable keyboard tray

  • Adjustable mouse platform

  • Corner bracket

  • Adjustable chair

  • Adjustable stool

  • Adjustable foot rest

  • Adjustable foot rocker

  • Adjustable monitor arm

  • Adjustable copy drawer/document holder

  • Telephone head set

  • Ergonomics Training

  • Other

  • 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.

  • 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.

  • Please call the MVC Office of Health and Safety (609-292-5258) to discuss this report or if we can provide any additional assistance.

  • Employee's Signature

  • Evaluator's Signature

  • Manager's Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.