Request for Ergonomic Assessment Form

Ergonomic assessments can assist in identifying risks associated with improper equipment use, repetitive tasks and poor workstation set-up. Ontario Tech University’s Environmental Health and Safety Officer can recommend changes to your workstation which can be taken into consideration when working on-campus or from your home office.

Before submitting this request for assessment, please complete Steps 1-3 on the Ergonomics Program webpage and inform your manager that you are submitting a request for assessment.

On the Ergonomics Program webpage, I have completed Step 1 (Complete the Workplace Self-Assessment Tool), Step 2 (Review the Position for Safety Diagram), and Step 3 (Explored the Ergonomics Resources Button).

On the Ergonomics Program webpage, I have completed Step 1 (Complete the Workplace Self-Assessment Tool), Step 2 (Review the Position for Safety Diagram), and Step 3 (Explored the Ergonomics Resources Button). Yes No
Request Date: Request Date: / MM / DD YYYY
Your Name: Your Name: First Last
Banner ID
Your Department/Faculty
Your Job Title:
Your Manager's Name: Your Manager's Name: First Last
Your Workstation Location (Building, Floor, Room Number):
Your Ontario Tech E-mail:
Reason for Request: (if you are currently experiencing any discomfort please detail)
Summary of Daily Tasks: (include % of time at each task)
When using your keyboard or mouse, are your forearms horizontal, at about a 90 degree (right) angle at the elbow, with shoulders and upper arms relaxed?

When using your keyboard or mouse, are your forearms horizontal, at about a 90 degree (right) angle at the elbow, with shoulders and upper arms relaxed? Yes No
Are your wrists in a straight position when using your keyboard or mouse?

Are your wrists in a straight position when using your keyboard or mouse? Yes No
When you look at the screen, is your head upright (not bent forward or backward)?

When you look at the screen, is your head upright (not bent forward or backward)? Yes No
Is your lower back supported by the curved part of the chair backrest?

Is your lower back supported by the curved part of the chair backrest? Yes No
When you are seated, are your thighs resting horizontally with a 90–110 degree angle at the hips?

When you are seated, are your thighs resting horizontally with a 90–110 degree angle at the hips? Yes No
Are you able to sit without feeling pressure from the chair seat on the back of your thighs or knees?

Are you able to sit without feeling pressure from the chair seat on the back of your thighs or knees? Yes No
Are your feet fully supported by the floor or a footrest?

Are your feet fully supported by the floor or a footrest? Yes No
Does your daily computer work exceed 4 hrs/day?

Does your daily computer work exceed 4 hrs/day? Yes No
Do you use a document holder?

Do you use a document holder? Yes No
Do you take frequent micro-breaks to stretch or move your body?

Do you take frequent micro-breaks to stretch or move your body? Yes No