Ergonomic Pre-Assessment

1. Employee Information

Your Name*

Your CSUN Email*

Your Title*

Department*

Select or enter value

Supervisor*

Has your supervisor been informed that you will be receiving an ergonomic assessment?*

Yes

No

Location*

Select

2. Biometrics

Answers in this section are voluntary only, but may assist EH&S in making recommendations during and following your in-person assessment. Answers will be shared with supervisors.

Height

(Feet and Inches. Ex: 5'6")

Age Range

<18

18-39

40+

Corrective Lenses

Select

Are you a proficient typist?

Select

Mousing Hand

Left

Right

Both

N/A

3. Task Allocation

Computer Usage*

(estimated hours per day, use decimals for partial hours)

Time Spent on the Phone*

(estimated hours per day, use decimals for partial hours)

Time Spent Video Conferencing*

(estimated hours per day, use decimals for partial hours)

Do you spend more than 20 minutes per day (on average) performing paper-based work?*

(e.g., transcribing from paper, working on paper)

Yes

No

4. Equipment

Please provide information about the equipment you are currently using.

When answering questions with multiple possible responses (e.g., you have different equipment when you work remotely), base your answers on the workstation where you spend the most time.

Do you share your workstation?*

Yes

No

Computing Device(s)*

You may select more than one.

Laptop

Desktop

Other

No Computing Device

Does your workstation currently have sit/stand capability?*

Yes

No

5. Discomfort Identification

Additional Information

Please provide any additional information or considerations that may assist with your assessment.