Date:
Name:
Campus:
Department:
Work Area:
Phone Number (W):
Email:
Supervisor Name:
Please answer all of the following questions to the best of your ability:
Have you completed the Online Office Ergonomics Self Assessment? Yes No
Have you attended an ergonomics training session (e.g. Lifting, Safety, Office Ergonomics)? Yes No
Describe any changes you have made to your work area based upon information from the ergo website, or training sessions:
What outstanding conditions or concerns do you have that still need to be addressed?
Do you have any ideas regarding potential actions to address these conditions or concerns?