Ergonomic Questionnaire Assessment

Home » Ergonomic Questionnaire Assessment

Ergonomic Assessment Questionnaire

Name *

First

Last

Email *

Company *

Gender *

Male
Female

Date of Birth *

Length of Employment *

This information I'm about to provide is related to my:

Home Workstation
Office Workstation

If both of the above options applies to you, please complete this questionaire twice. Select each of the above options (Home Workstation or Office Workstation) for each questionnaire, then proceed to answer each accordingly to your specified workstation.

Height (cm) *

Height of desk from floor to where the keyboard sits (cm) *

Rest Breaks (breaks/hr) *

What type of computer do you predominantly work on? *

Desktop
Laptop
Both

If you use a laptop, do you use an external keyboard and mouse? *

Yes
No

Are you a proficient typist? *

Yes
No

Do you use a numeric keypad? *

Yes
No

Have you ever used or currently using any ergonomic equipment or tools at work? *

Yes
No

If you've answered "Yes" to the above please specify below:

How many hours per day do you spend sitting at your desk/workstation using your laptop/desktop?

Are you currently or have you previously experienced discomfort or pain while working at your current workstation? *

Yes
No

If you've answered "Yes" to the previous question, please specify where in your body you are or have experienced these symptoms (neck, shoulders, back etc.) *

Do you do any repetitive movements of arms/ shoulders? *