Workplace Ergonomics Assessment Intake Form Form Template

Collect information to assess ergonomic needs and workplace adjustments for employees.

Full Name *

Date of Birth *

Position/Job Title *

Date of Assessment *

Primary Workstation Type *

Do you experience any discomfort or pain while working at your current workstation? *

If yes, please describe the discomfort or pain (e.g., back pain, wrist pain, neck strain)

How many hours do you spend at your workstation per day?

If you selected 'Other', please specify

Do you feel your current chair and desk setup supports proper posture?

Have you received training or guidance on proper workstation ergonomics?

What improvements or adjustments would help make your workstation more comfortable?

Additional comments or concerns about your workstation

Signature of Employee *

Date of Submission *