Ergonomic Assessment Request

Complete the following questions to the best of your knowledge. EH&S will coordinate an evaluation of your work space.

Name Name First Last
Department
I am working onsite
I am working remotely offsite
Building and Room Number
Email
Phone Phone - ### - ### ####
WORKSTATION DESCRIPTION

Please select all of the items that currently describe your workstation and work space.
I cannot do the following in my workspace

I cannot do the following in my workspace Adjust my knee and hip angles Support my heels and toes Place my arms comfortably at my sides Place my hands parallel to the floor Support my wrists Other Other
My workstation does not have the following:

My workstation does not have the following: Enough clearance for feet, knees, and legs Sufficient space for thighs between work surface and seat Place to rest arms during long/intensive keyboarding tasks Hands-free telephone option when telephone work is combined with hand tasks Other Other
My chair does not do the following:

My chair does not do the following: Provide back support Adjust easily Adjust to different lengths and heights I don't use a chair Other Other
I am using the following devices in my workspace

I am using the following devices in my workspace Laptop PC Tablet
Please describe a typical workday (number of hours on the computer, types of tasks, breaks scheduled, etc.)
WORKSPACE PHOTOS

Please attach pictures of you sitting in your workspace - front, side, and rear (with you facing towards your computer). Make sure to include your foot and leg space in the pictures.
Front

Attach Files
Side

Attach Files
Rear

Attach Files