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SELF EVALUATION FORM
TESTIMONIAL
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Self Evaluation Form
General Information
Company Name* :
Employee Name* :
Department :
Email address* :
Supervisor Name :
Contact No* :
Purpose of Evaluation
Are you having discomfort?
Select
Yes
No
If the answer is "Yes", how long have you been having the discomfort?
Select
3-6 months
6-12 months
12-18 months
>18 months
Which part of your body is having discomfort?
Select
Neck
Shoulders
Upper arms
Forearm
Wrists
Fingers
Thighs
Calves
Foot
Eyes
Upper back
Lower back
Based on the question above, is the discomfort on the right or left side?
Select
Right
Left
Both
Based on your described discomforts above, are you having numbness or tingling sensations?
Select
Yes
No
Ergonomic Risk Evaluation
How frequent do you sit at your workstation? (Number of hours)
Select
8 hrs
6-8 hrs
4-6 hrs
2-4 hrs
<2 hrs
How frequent do you stand at your workstation? (Number of hours)
Select
8 hrs
6-8 hrs
4-6 hrs
2-4 hrs
<2hrs
When you sit all the way to the back of the chair, how far is the monitor being away from you?
Select
< 1 arm distance
1 arm distance
2 arm distance
When you look at the monitor or monitors, do you need to turn your neck?
Select
Yes
No
If you use laptop computers, do you put it on a docking station?
Select
Yes
No
If your laptop computer is not on a docking station, do you use a laptop stand?
Select
Yes
No
Is your desk height adjustable?
Select
Yes
No
Is your chair adjustable?
Select
Yes
No
Is your feet either placing completely on the ground or with a footrest?
Select
Yes
No
If you are standing at your workstation, do you use any anti-fatigue mat support?
Select
Yes
No
If you are frequently on the phone, do you use a headset?
Select
Yes
No
If you have a standing desk, do you have an anti-fatigue mat?
Select
Yes
No
Do you use a footrest when you stand?
Select
Yes
No
Do you look down all the time when you are working?
Select
Yes
No
How often do you take breaks while working?
Select
every 30-40
every hr
every 2 hr
>2 hrs
Do you need to lift objects in your job?
Select
Yes
No
If you do lift objects while working, how often do you lift?
Select
Once every hr
>5 to 10 times in an hr
10 to 20 times in an hr
>20 times in an hr
Usually how heavy is the object that you need to lift or carry?
Select
5-10 lb
10-20lb
20-30lb
>30lb
How do you feel after you finish the day of work?
Select
Energetic
little tired
Very tired
Exhausted
Comments