Ergonomics Assessment Ergonomic Preassessment Form Enter Ergo Code Step 1: Please fill in your personal information below: Personal Information Email First and Last Name Job Status Full TimePart TimeContract 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 How many years have you worked on a computer? How many hours a day do you work on a computer? How many days per week do you work on a computer? 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: Sitting: % + Standing: % + Walking: % = 100% Step 3 Please indicate the duration (hours) that you would perform the tasks below on a typical work day. Task Breakdown Keyboarding and Mousing? <11-23-45-67-89-10>10 Reviewing documents? <11-23-45-67-89-10>10 Speaking on the telephone? <11-23-45-67-89-10>10 Filing, sorting, or collating documents? <11-23-45-67-89-10>10 Reading documents on the computer monitor? <11-23-45-67-89-10>10 Handwriting notes and documents? <11-23-45-67-89-10>10 Using your computer while on the telephone? <11-23-45-67-89-10>10 Meeting with others? <11-23-45-67-89-10>10 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? 12345678910 Does your concern(s) interfere with life outside of work? 12345678910 Does your concern(s) interfere with sleep? 12345678910 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. Δ Thank you for taking the time to fill out the Ergonomics Preassessment Form. If you have questions, contact us.