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Office Worker Ergonomic Questionnaire
Name:
Email:
 
Last Name
First Name
M.I.
Department:
Code:
Position Classification:
Time in Position:
Building:
Room:
 Telephone:
Department Head/Director:
  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)
Arm(s)
 
Back  
Elbow(s)  
Eye(s)  
Hand(s)  
Leg(s)  
Neck  
Shoulder(s)  
Wrist(s)  
Other
(Please Specify)

  1. If you have discomfort do you believe it may be work related?
Yes  
No

  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:

Computer Use:
Hours  
Sitting:
Hours  
Standing:
Hours  

Lifting, Bending, Twisting:
Hours
Other:
Hours
(Please Specify)

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

 

For more information visit the Ergonomics Program web page.

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Last Modified: Friday, July 11, 2008
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