Ergonomic Assessment - NIU - Environmental Health and Safety

Environmental Health and Safety

Ergonomic Assessment Questionnaire

Section 1: Pre-Assessment

Please complete the following prior to your workstation assessment. This information is collected for the purpose of better understanding your work activities.


 

 

 

8. Gender:

9. Height:

11. Do you work:

13. Is your workstation used during another shift?

14. Please fill in the percentage of your time spent for each activity:

15. Please fill in the percentage of your time spent for each activity:

16. On average, how many hours per day do you spend using a computer?

17. On average, how many times per hour do you get up from your desk?

18. How often do you use the numeric keypad at the right of the keyboard?

19. Please describe your typing style:

20. Please indicate your dominant hand:

21. On average, how many hours a day do you spend on the phone?

22. Do you cradle the phone between your head and neck?

23. Do you wear corrective lenses?

24. If yes, do you wear them for:

25. If yes, do you wear any of the following:

26. Do you tend to experience any of the following symptoms?


Section 2: Discomfort Survey

Please complete the Pre-Assessment discomfort survey prior to your workstation assessment by checking the appropriate boxes.


NECK

During the last work week, how frequent was your discomfort?
During the last work week, how severe was your discomfort?
How has your discomfort interfered with your ability to work?

SHOULDER (RIGHT)

During the last work week, how frequent was your discomfort?
During the last work week, how severe was your discomfort?
How has your discomfort interfered with your ability to work?

SHOULDER (LEFT)

During the last work week, how frequent was your discomfort?
During the last work week, how severe was your discomfort?
How has your discomfort interfered with your ability to work?

UPPER BACK

During the last work week, how frequent was your discomfort?
During the last work week, how severe was your discomfort?
How has your discomfort interfered with your ability to work?

UPPER ARM (RIGHT)

During the last work week, how frequent was your discomfort?
During the last work week, how severe was your discomfort?
How has your discomfort interfered with your ability to work?

UPPER ARM (LEFT)

During the last work week, how frequent was your discomfort?
During the last work week, how severe was your discomfort?
How has your discomfort interfered with your ability to work?

LOWER BACK

During the last work week, how frequent was your discomfort?
During the last work week, how severe was your discomfort?
How has your discomfort interfered with your ability to work?

FOREARM (RIGHT)

During the last work week, how frequent was your discomfort?
During the last work week, how severe was your discomfort?
How has your discomfort interfered with your ability to work?

FOREARM (LEFT)

During the last work week, how frequent was your discomfort?
During the last work week, how severe was your discomfort?
How has your discomfort interfered with your ability to work?

WRIST (RIGHT)

During the last work week, how frequent was your discomfort?
During the last work week, how severe was your discomfort?
How has your discomfort interfered with your ability to work?

WRIST (LEFT)

During the last work week, how frequent was your discomfort?
During the last work week, how severe was your discomfort?
How has your discomfort interfered with your ability to work?

HIPS/BUTTOCKS

During the last work week, how frequent was your discomfort?
During the last work week, how severe was your discomfort?
How has your discomfort interfered with your ability to work?

THIGH (RIGHT)

During the last work week, how frequent was your discomfort?
During the last work week, how severe was your discomfort?
How has your discomfort interfered with your ability to work?

THIGH (LEFT)

During the last work week, how frequent was your discomfort?
During the last work week, how severe was your discomfort?
How has your discomfort interfered with your ability to work?

KNEE (RIGHT)

During the last work week, how frequent was your discomfort?
During the last work week, how severe was your discomfort?
How has your discomfort interfered with your ability to work?

KNEE (LEFT)

During the last work week, how frequent was your discomfort?
During the last work week, how severe was your discomfort?
How has your discomfort interfered with your ability to work?

LOWER LEG (RIGHT)

During the last work week, how frequent was your discomfort?
During the last work week, how severe was your discomfort?
How has your discomfort interfered with your ability to work?

LOWER LEG (LEFT)

During the last work week, how frequent was your discomfort?
During the last work week, how severe was your discomfort?
How has your discomfort interfered with your ability to work?

EYES

During the last work week, how frequent was your discomfort?
During the last work week, how severe was your discomfort?
How has your discomfort interfered with your ability to work?