Ergonomics Assessment

Ergonomic Preassessment Form

    Enter Ergo Code

    Step 1:

    Please fill in your personal information below:

    Personal Information

    Email

    First and Last Name

    Employer

    Location

    Phone Number

    Department

    Job Title

    Years on the Job

    Height

    Age

    Dominant Hand

    RightLeftBoth

    Step 2

    Answer the following questions about your job duties:

    Job Duties




    Are there non-computer tasks associated with your job? YesNo
    Are there tasks that take you away from your workstation periodically? YesNo
    Do you take relief breaks (5 min each hour)? YesNo
    What percentage of your time is spent doing the following:


    Step 3

    Please indicate the duration (hours) that you would perform the tasks below on a typical work day.

    Task Breakdown

    Keyboarding and Mousing?

    Reviewing documents?

    Speaking on the telephone?

    Filing, sorting, or collating documents?

    Reading documents on the computer monitor?

    Handwriting notes and documents?

    Using your computer while on the telephone?

    Meeting with others?

    Step 4

    Mark the areas where you are feeling any discomfort, pain, tingling, and/or numbness:

    Ergonomic Concerns

    Left

    FingersHandWristElbowForearmShoulderHeadEyeNeckBackLegFoot

    Right

    FingersHandWristElbowForearmShoulderHeadEyeNeckBackLegFoot

    Description of Ergonomic Concerns

    Describe how your symptom(s) feel under the following circumstances:

    Does your concern(s) interfere with work?

    Does your concern(s) interfere with life outside of work?

    Does your concern(s) interfere with sleep?

    Step 5

    Please answer the questions about your workstation:

    Workstation

    Keyboard

    Is your keyboard comfortable? YesNo
    Can you adjust the height of your keyboard? YesNo

    Computer Screen

    Is the top of your computer screen even with your eyebrows? YesNo
    Does your computer screen have any glare? YesNo
    Are you able to comfortably read your computer screen? YesNo
    Do you have an adjustable document holder? YesNo
    Is your computer screen within arm’s reach from where you sit? YesNo

    Chair

    Is your chair comfortable to sit in? YesNo
    Is your chair adjustable? YesNo
    Do you know how to properly adjust your chair? YesNo
    Does your chair provide enough back support? YesNo
    Are your feet resting flat on the ground (or footrest)? YesNo

    Desk:

    Do you have adequate space under your desk for your legs? YesNo
    Are frequently used items on your desk within arm’s reach? YesNo

    Step 6

    Please answer the following question below:

    Background

    Please provide any additional information related to your ergonomic concerns:

    Push submit to send in your answers.

     

    Thank you for taking the time to fill out the Ergonomics Preassessment Form. If you have questions, contact us.