Employee Name * Department * Building Name * Office/Room Number * Job Title * Phone Number * Email * Mail Stop * Workstation component you would like to have evaluated Check all that apply. Chair Seat Chair Back Chair Armrests Keyboard/Mouse Desk Computer Monitor Telephone Handheld Tool Other Other Workstation Component Look around your workstation and recall daily activities. Check all that apply. You currently use a sit-stand or stand-biased desk You spend most of the day typing Your job requires that you lift heavy loads regularly Your job requires that you perform the same repetitive motion for most of the day Your job requires bending, crouching, or stooping repeatedly or for prolonged periods Your job requires repetitive or prolonged reaching above your shoulders Your workstation is an office Your workstation is NOT well-lit Your workstation is NOT climate-controlled Your workstation is NOT an office Describe your workstation Briefly describe the work-related duties performed using the selected component(s) and daily activities. * (Please DO NOT include any medical concerns or diagnosis.) If you have any questions, contact an ergonomic specialist at email@example.com.