<p> Ergonomic Evaluation Request Form </p><p>Please complete, sign and send to Robin McClain, Date: 4/4/2018 Risk & Compliance Manager, in Human Resources</p><p>Employee Name: ______Job Title: ______Location (Campus/Bldg/Fl/Rm #): ______E-Mail: ______Dept.: ______Phone: ______</p><p>Number of Hours worked/week: _____ Time on this job: ____Years ____Months</p><p>Supervisor Name: ______Job Title: ______E-Mail: ______Phone: ______</p><p>Evaluator: ______Evaluation Date: ______</p><p>Background Information About Employee Condition</p><p>1. What specific work task or tasks, if any, do you think contribute to or cause your discomfort?</p><p>2. Did any specific activity or event trigger your discomfort? Yes No If yes, describe: </p><p>3. What do you think could improve this condition?</p><p>4. Are you currently seeing a doctor for this problem? Yes (Specialty: ______) No If so, what advice or information did you receive about work schedule or restricted activities, or treatment prescribed?</p><p>5. Did the prescribed treatment improve this condition? Yes No</p><p>6. How much time have you been off work in the last year due to this problem? months days</p><p>7. How many days were you restricted due to this problem? months days</p><p>8. Describe your Hobbies and time spent on each.</p><p>1 2 Comfort/Discomfort Survey</p><p>Use the drawing below as a guide to areas on your body which experience discomfort while performing your job or discomfort you feel results from your job. For each area of the body, rate how often the discomfort occurs (Frequency) and how often it negatively affects your work performance (Productivity). Ratings are based on the following scale:</p><p>1 Never 2 Rarely 3 Occasionally 4 Frequently 5 Constantly</p><p>Area of Body Rating Area of Body Rating A. Headache Frequency H. Lower Back Frequency Productivity Productivity I. Buttocks B. Vision Frequency /Hips Frequency Productivity Productivity J. Thighs C. Neck Frequency Left Productivity Frequency D. Shoulder Right Productivity Left Frequency Frequency Productivity K. Knee Productivity Right Frequency Left E. Elbow Productivity Frequency /Forearm Right Productivity Left Frequency Frequency Productivity L. Shin Productivity Right Frequency Left Productivity Frequency F. Wrist/Hand Right Productivity Left Frequency Frequency Productivity M. Ankle/Foot Productivity Right Frequency Left Productivity Frequency Right Productivity G. Upper Back Frequency Frequency Productivity Productivity </p><p>Additional Comments: </p><p>Employee Signature: Date: </p><p>Job Documentation Administrative Assistant Programmer Customer Service Rep. Supervisor/Manager Custodial (office) Marketing/Sales 1. Which job category best describes this job? Officer/Director Food Services 3 Maintenance Mailroom Employee/ Workspace Evaluation Staff Function Grounds (To be completed by Evaluator) Loading/Shipping Other ______ Work surface is: 2. How many people work at your workstation?  Fixed height at “ Sole occupant Desk share ( ___ people)  Maintenance adjustable at ”& ”  User adjustable between ”& ” 3. Which of the following best describes the task(s) which cause discomfort?  Keyboard/mouse support surface is: Performed without repetition  Fixed height at “ Performed with some repetition  Maintenance adjustable at ” & ” Performed repetitively  User adjustable between “ & “</p><p>4. What computer tasks are typically performed and  Monitor size and type: what percentage of the day is spent performing each 15” Flat task? 17” Contoured  Customer Service % of day 19”  Data Entry % of day 21”= or greater  Word Processing % of day  Graphics/CAD % of day  Wrist Rest:  Other % of day Gel-Keyboard with base Gel-Mouse with base 5. Is your computer use? Gel-Keyboard and Mouse Infrequent Frequent Gel-Keyboard Short periods Long Periods No wrist rest Silicon Graphics Mouse 6. Is your keying/typing? Other ______Continuous Intermittent For approximately how many ______hrs/day  Currently using telephone Cradle 7. Which of the following best describes your computer Headset usage? Earpiece < 1 hour per day Headphone – one ear 1 - 2 hour per day Headphone – two ear 3 - 4 hours per day Other ______4 - 5 hours per day > 5 hours per day  Telephone moved or longer cable Yes No</p><p>8. How long you have you been performing this job?  Chair Adjustable? Yes No < 6 months 6 - 12 months 1 - 2 years Brand ______> 2 years  Foot Rest Present? Yes No 9. What types of computer programs do you use? Workstation layout (sketch) – to be completed on back of form.</p><p>Adapted from Columbia University, in the City of New York www.ehs.columbia.edu/ErgonomicOfficeEvaluationForm.doc - 2008-11-13 10. What OTHER tasks do you perform in addition to computer use? </p><p>11. Is your telephone use: Infrequent Frequent Short periods Long Periods For approximately how many ____ hours/day</p><p>4</p>