Environmental Health & Safety

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Instructions:  Use this form to request an ergonomic evaluation of your chair / seat. All fields are required to be completed.

Name: (required)
Email: (required)
Title:
Phone:
Supervisor:
Department
Height:
Weight:
Leg Inseam (inches):
How many hours per day do you sit in your office chair?
How often do you take breaks (physically get up and walk away from your workstation)?
Please indicate areas of discomfort below. For more information review the Body Discomfort Areas diagram.	Arm (left forearm) Arm (right forearm) Back (low) Buttock Elbow (left) Elbow (right) Hand (left) Hand (right) Hip Joints Neck Pelvic area Sciatica Shoulder (left joint) Shoulder (right joint) Shoulder (tops) Shoulder Blades Tailbone / Coccyx Wrist (left) Wrist (right)