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Template: Medical Intake
Workplace Ergonomics Assessment Intake Form
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Collect information to assess ergonomic needs and workplace adjustments for employees.
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Full Name
*
Date of Birth
*
Position/Job Title
*
Date of Assessment
*
Primary Workstation Type
*
Desk (Seated)
Standing Desk
Hybrid (Sit/Stand)
Field Work
Other
Do you experience any discomfort or pain while working at your current workstation?
*
Yes
No
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?
Do you use any of the following accessories at your workstation? (Check all that apply)
Ergonomic Chair
Foot Rest
Monitor Stand
Keyboard Tray
Ergonomic Mouse
Adjustable Desk
Other (please specify)
If you selected 'Other', please specify
Do you feel your current chair and desk setup supports proper posture?
Yes
No
Not Sure
Have you received training or guidance on proper workstation ergonomics?
Yes
No
What improvements or adjustments would help make your workstation more comfortable?
Additional comments or concerns about your workstation
Signature of Employee
*
Sign Here
Date of Submission
*
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