Ergonomic Consultation Request Form

General Information

Company Name* :
Number of Employees to be assessed* :

Purpose of Evaluation

Having discomfort?
Onsite assessment or remote assessment?

For remote assessments, please answer the following:

What is your height in feet
What is your height in inch
What is the measurement of your desk/work surface in inch (Length)
What is the measurement of your desk/work surface in inch (Width)
How many hours do you work at the current workstation per day?
How many hours do you spend on the following activities: Computer operation (Typing)
Computer operation (Mousing)
Phone use
Do you use phone set while on the phone
Writing
Read documents on desk
Calculator usage
Do you alternate between sit/stand while working
Did you have any past injuries/surgeries
If the answer above is "Yes", please describe below:

Please Email 4 photos (View from back, View from right, View from left, View from overhead) for evaluation on S_Li@ergosolstice.com

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