Office Worker Ergonomic Questionnaire


  1. If you wear prescription eyewear please specify what type: (Check all that Apply)
 
  1. Have you recently experienced or are you currently experiencing an abnormal amount of pain or discomfort in the following areas? (Check all that Apply)
 
 
 
 
 
 
 
 
 


  1. If you have discomfort do you believe it may be work related?

  1. Due to pain or discomfort indicated above, have you initiated a worker's compensation  claim or are you currently receiving treatment from a physician, physical therapist, chiropractor, or other health care professional?

  1. Indicate the number of hours you spend performing the following activities in a standard work day:


  1. Please use the following space to give further relevant information about your ergonomic status.



 

For more information visit the Ergonomics Program web page.