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Office Ergonomic Assessment Form
Office Ergonomic Assessment Form
Full Name of Employee
*
Date
*
MM slash DD slash YYYY
Company
*
Position
*
Age
*
Please enter a number from
18
to
99
.
Height
*
Please enter in format like 6ft 2in or 6'2"
Work Schedule
*
Full Time
Part Time
Work Hours per Week
*
Please enter a number from
1
to
99
.
Hours of Computer Use at Work per Day
*
Please enter a number less than or equal to
24
.
Hours of Computer Use at Home per Day
Please enter a number less than or equal to
24
.
Hours of Phone Usage at Work per Day
*
Please enter a number less than or equal to
24
.
Speaker phone?
*
Yes
No
Headset?
*
Yes
No
Hand Dominance
*
Right
Left
Mousing Hand
*
Right
Left
Hidden
Page 2 of Office Ergonomic Assessment
Hours of Device Usage per Day (cell phone, tablet, etc)
*
Please enter a number less than or equal to
24
.
Number of Breaks per Day
*
Please enter a number less than or equal to
10
.
How Long is your Lunch Break in Minutes?
*
Please enter a number less than or equal to
99
.
How Long are your Short Breaks in Minutes?
*
Please enter a number less than or equal to
99
.
Vision - Do You Wear Eye Glasses or Corrective Lenses?
*
No
Yes
If Yes, Wear Them for Reading, Distance or Both?
N/A
Reading
Distance
Both
Eye Dominance
*
Unsure
Right
Left
Do You Have Discomfort?
*
No
Yes
If Yes, Describe Your Discomfort
Hidden
Notes:
Hidden
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Email
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