Ergonomic Workstation Assessment

Environmental Health & Safety

Section 1: Pre-Assessment Information

Please respond to the following as it pertains to your current workstation/assignment.

First Name

Last Name

CPP Email

Please enter your email address (e.g., ####@cpp.edu)

Department

Division

Hours Per Day on Work Computer

Hours Per Day Using Phone

Proficient Typist

How long have you been at this workstation?

Do you use a numeric keypad?

Amount of rest breaks in minutes per day

Office Location

Provide building, floor, and room number

Your Height in feet, inches

(Example: 5', 5")

Dominant Hand

Corrective Lenses

Type of Lenses

Section 2: Pre-Assessment Discomfort Survey

Complete the Pre-Assessment Discomfort Survey (below). When received you will be contacted to schedule your workstation evaluation.

Check all that apply.

Do you experience discomfort in your:

Neck

Upper back

Lower back

Eyes

Left Shoulder

Right Shoulder

Left Upper Arm

Right Upper Arm

Left Elbow

Right Elbow

Left Forearm

Right Forearm

Left Wrist

Right Wrist

Left Hand

Right Hand

Left Hip

Right Hip

Right Thigh

Left Knee

Right Knee

Left Foot

Right Foot

Other

Describe other discomfort

Post-Assessment Survey

We will send you a Post-Assessment Update Survey in approximately four (4) to six (6) weeks following your evaluation. If you have any questions either in completing your survey or the survey update, please contact Lori Inarda at lainarda@cpp.edu.

Send me a copy of my responses

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