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Ergonomic Evaluation (Form 430300-9)

get more information on COVID-19

Due to our County Public Health Department social distancing recommendations and State and local orders, the Preventive Ergonomic Program in-person evaluations are on hold until further notice. The only options at this time are a phone consultation or virtual evaluation, which requires prior authorization from Risk Management. All requests are reviewed on a case-by-case basis.

If you have questions or would like to request a phone consultation or virtual evaluation, please email Sean Mullen, Safety Manager, at ergolab@acgov.org

Please note:
    (1) No more than one preventive ergonomic evaluation, per employee, within a five (5) year period; and
    (2) There are no automatically approved follow-up appointments.

We appreciate your understanding during this difficult time. We will update this message as additional information becomes available.

Please note: If you have a workers' compensation claim, contact the Sedgwick claims examiner.


Yes   No
Contact the Sedgwick claims examiner to request an ergonomic evaluation.
Yes   No

Requester (Employee completing this form)

Employee to be Evaluated

Requester (Employee completing this form)

Group's Department Information

Supervisor-Designee Information

Supervisor Information