Individual Ergonomics Evaluation

Do you perform repetitive tasks? (Repetition is 100 reps per hour to 200 per day.)*

YesNoUnsure

Does your daily routine require repeated heavy lifting? (Over 50 lbs.)*

YesNoUnsure

Does your daily routine require extreme reaching?*

YesNoUnsure

Does your daily routine require either sitting or standing for an extended period of time? (1-3 hours.)*

YesNoUnsure

Does your daily routine require awkward back angles held for extended periods of time? (1-3 hours.)*

YesNoUnsure

Does your daily routine require awkward elbow angles held for extended periods of time? (1-3 hours.)*

YesNoUnsure

Does your daily routine require awkward wrist flexion angles held for extended periods of time? (1-3 hours.)*

YesNoUnsure

Does your daily routine require awkward wrist extension angles held for extended periods of time? (1-3 hours.)*

YesNoUnsure

Does your daily routine require awkward back or hip flexion angles held for extended periods of time? (1-3 hours.)*

YesNoUnsure

Typical Work Routine (Daily working hours, meetings, breaks, etc.)*

Before Evaluation Photo - please include your complete workstation (i.e. keyboard, mouse, mouse pad, wrist pad, chair, foot rest, accessories, etc.)*

Please book an appointment with Monique, our Benefits Administrator, to further discuss and get next steps using the following link:

BOOK HERE!

I used the link above to book an appointment.*

Yes, I confirm.

Today's Date*

Date

Evaluator's Legal Name*

First NameLast Name

Evaluator's CPR Email Address*

example@example.com

Potential postural issues - Desk (Surface should be 25in - 27in above the floor and 30 in deep.)*

Potential postural issues - Chair (Chair should be 18in W, 15in L, base 24in around, and breathable fabric with back rest at least 18in tall, 14in W.)*

Potential postural issues - Screens (18-30in away from eye view, top of line display should be slightly below the eye level, tilted slightly to reduce reflection and glare, clean and free of debris.)*

Potential postural issues - Keyboard, including laptop keyboard (Detached keyboards should be sloped at about 10-15 degrees, wrists should be relaxed and straight or parallel armrest elbows at 90 degree angle, and easily within reach.)*

Potential postural issues - Mouse (Wrists should be relaxed and straight or parallel armrest elbows at 90 degree angle, same level as the keyboard, and easily within reach.)*

Potential lighting issues*

Changes made during evaluation*

Additional notes and changes made during evaluation:*

Educational materials provided*

Product recommendations*

Further details on product recommendations. - Please provide links to products or upload picture(s). *

File Upload

Individual Ergonomics Evaluation

Workstation Analysis

Typical Work Routine

HR Assessment