Self Evaluation Form

General Information

Company Name* :
Employee Name* :
Department :
Email address* :
Supervisor Name :
Contact No* :

Purpose of Evaluation

Are you having discomfort?
If the answer is "Yes", how long have you been having the discomfort?
Which part of your body is having discomfort?
Based on the question above, is the discomfort on the right or left side?
Based on your described discomforts above, are you having numbness or tingling sensations?

Ergonomic Risk Evaluation

How frequent do you sit at your workstation? (Number of hours)
How frequent do you stand at your workstation? (Number of hours)
When you sit all the way to the back of the chair, how far is the monitor being away from you?
When you look at the monitor or monitors, do you need to turn your neck?
If you use laptop computers, do you put it on a docking station?
If your laptop computer is not on a docking station, do you use a laptop stand?
Is your desk height adjustable?
Is your chair adjustable?
Is your feet either placing completely on the ground or with a footrest?
If you are standing at your workstation, do you use any anti-fatigue mat support?
If you are frequently on the phone, do you use a headset?
If you have a standing desk, do you have an anti-fatigue mat?
Do you use a footrest when you stand?
Do you look down all the time when you are working?
How often do you take breaks while working?
Do you need to lift objects in your job?
If you do lift objects while working, how often do you lift?
Usually how heavy is the object that you need to lift or carry?
How do you feel after you finish the day of work?

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