Ergonomic Assessment

• Name

  Name * First Last
• Phone

  Phone * - ### - ### ####
• Email *
• Department *
• Location (Building/Address and Room Number): *
• Job Title *
• Supervisor *
• Date of hire/transfer

  Date of hire/transfer * / MM / DD YYYY

  
• Reason for Evaluation: *
  Reason for Evaluation:

  New Hire Office Move Employee requested Supervisor requested Other Other
• How many hours per day do you work? *
• How many days per week? *
• If for computer/workstation assessment, check that apply:
  Average Daily Computer Use: *
  If for computer/workstation assessment, check that apply:
  Average Daily Computer Use:

  Less than 2 Hrs 2-4 hrs More than 4 hrs
• Symptoms Reported: *
  Symptoms Reported:

  Not experiencing discomfort Has had some discomfort in past Currently in discomfort Discomfort interferes with work Other Other
• Explain your concern: *
  Describe any concerns you may be experiencing Must be between 5 and 250 characters.   Currently Entered: 45 characters.
• Spam Protection. Please answer this question:
  What is the sum of 8 and 1 ?