Office Worker Ergonomic Questionnaire Last Name: First Name: Middle Initial: Email: Department: Dept. Number: Position Classification: Time in Position: Building: Room: Telephone: Department Head/Director: If you wear prescription eyewear please specify what type: (Check all that Apply) Glasses Bifocals Trifocals Contact Lenses Have you recently experienced or are you currently experiencing an abnormal amount of pain or discomfort in the following areas? (Check all that Apply) Arm(s) Back Elbow(s) Eye(s) Hand(s) Leg(s) Neck Shoulder(s) Wrist(s) Other Please Specify Other Pain or Discomfort: If you have discomfort do you believe it may be work related? Yes No 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? Yes No Indicate the number of hours you spend performing the following activities in a standard work day: Computer Use Hours: Sitting Hours: Standing Hours: Lifting, Bending, Twisting Hours: Other Hours: Please Specify Other Hours: Please use the following space to give further relevant information about your ergonomic status. More Information (Optional): [Your user agent does not support frames or is currently configured not to display frames. However, you may visit the related document.] Recaptcha Challenge Field Recaptcha Response Field For more information visit the Ergonomics Program web page.