ERGONOMIC RESOURCE FUND PROGRAM
REIMBURSEMENT FORM
FORM B
Revision Date:03162015
Revised By: RF
FOLLOW THE STEPS BELOW TO REQUEST REIMBURSEMENT (Managers or Budget Managers):
□
Complete & Attach workstation assessments to determine equipment need: Provide Self Evaluation document to SR&S
and ensure that the SR&S Ergonomic Evaluation is completed.
□
Complete & Provide Training Acknowledgement: Ensure participating employee has completed either an Instructor
lead or self-administered training (provide signed training acknowledgement sheet):
http://www.csusm.edu/srs/training/index.html#Ergonomics.
□
Apply for Ergonomics Resource Funds: Complete Ergo Resource Fund Program Application.
REIMBURSEMENT DATA (Please Print Clearly)
DEPARTMENT: ___________________________________
EMPLOYEE (last name, first): ________________________________________________________________________________
PHONE: ___________________________________________ E-MAIL: _____________________________________
MANAGER: ____________________________________ BUDGET MANAGER___________________________________
MANAGER’S (MPP) PHONE: ______________________ MANAGER’S E-MAIL: ______________________________________
EQUIPMENT REIMBURSEMENT WORKSHEET (Please Print Clearly)
Equipment
Vendor
Actual Cost
A
B
C
$
$
$
Reimbursement Amount Requested: Review Chart On SRS Web Page→
□
□
Reimbursed Amount
$
$
$
$
Provide chart field string: _________________________________________________ route to your MPP for approval.
Submit paperwork to SR&S: Send (1) completed form B (2) Workstation Self Evaluation form A and (3) applicable invoices to SRS via
intercampus mail at Craven 4700. A wet signature Ergonomic Resource Fund form B is required to be received by SR&S.
Ergonomic Resource Fund Limits and Requirements:
1. Applies only to: a.) CSUSM Employees; b.) Furniture/equipment to be used at CSUSM; c.) individual employee purchase of
furniture/equipment (non-fixtures and not associated with large-scale renovation projects); d.) SR&S approved furniture and
equipment (contact SR&S at x4502 for approval of products).
2. Limits/deadline: Not to exceed $1000 per employee (per year or per location). Ergonomic Resource Fund Program effective until
established funds are depleted or by April 15th. A submission of this form does not guarantee reimbursement.
3. Workers Compensation Cases: Please work with the WCC. Employee must receive a SR&S coordinated ergonomic evaluation.
4. Preventative Cases: Employees must complete self-evaluation and request an RM&S ergonomic evaluation.
5. Timeline: Implementation of workstation evaluation recommendations, including the ordering of specific furniture/equipment,
within 90 days of receipt of the SR&S ergonomic evaluation report.
6. Submissions: Applicable paperwork of the amount paid for the equipment (invoice/proposal, etc.), Workstation Self Evaluation,
training certificate and this form in order for the package to be completed for the transfer of funds. Incomplete Packets will not be
processed.
I, the undersigned, have read, understood and accepted the terms, conditions and requirements of the Ergonomic Resource Fund Program;
_______________________________________________
Manager (MPP) or Delegated Authority
__________________________
Date
SR&S Specialist/Director Review (initials) ____________________________ Date ______________________