Ergonomics Requests UF Libraries Facilities Ergonomic Evaluation Questions about the form? Call the department at (352) 273-2575Name* Today's date* MM slash DD slash YYYY Department* Telephone number*Building* Room number* Email address* Enter Email Confirm Email Supervisor* Evaluation date* MM slash DD slash YYYY Symptoms: Respond to each question by marking the appropriate box to indicate how often you have recently experienced the described symptom.Pain or stiffness in your arms 2x per month or less 1x per week or less 2 to 4 days per week Daily Pain or stiffness in your neck 2x per month or less 1x per week or less 2 to 4 days per week Daily Pain or stiffness in your shoulders 2x per month or less 1x per week or less 2 to 4 days per week Daily Pain or stiffness in your back 2x per month or less 1x per week or less 2 to 4 days per week Daily Pain or stiffness in your wrist or hand 2x per month or less 1x per week or less 2 to 4 days per week Daily Pain or stiffness in your legs 2x per month or less 1x per week or less 2 to 4 days per week Daily Eyestrain 2x per month or less 1x per week or less 2 to 4 days per week Daily Other Factors: Indicate whether the following create discomfort for you by marking the appropriate box.Chair 2x per month or less 1x per week or less 2 to 4 days per week Daily Backrest 2x per month or less 1x per week or less 2 to 4 days per week Daily Legroom 2x per month or less 1x per week or less 2 to 4 days per week Daily Table height 2x per month or less 1x per week or less 2 to 4 days per week Daily Keyboard height 2x per month or less 1x per week or less 2 to 4 days per week Daily Monitor height 2x per month or less 1x per week or less 2 to 4 days per week Daily Mouse 2x per month or less 1x per week or less 2 to 4 days per week Daily Size of work space 2x per month or less 1x per week or less 2 to 4 days per week Daily Lighting level 2x per month or less 1x per week or less 2 to 4 days per week Daily Glare from screen 2x per month or less 1x per week or less 2 to 4 days per week Daily Place to rest arms 2x per month or less 1x per week or less 2 to 4 days per week Daily Wear glasses Yes No Wear contacts Yes No Daily computer use 2 hours 4 hours 6+ hours Daily phone use <1 hour 1 - 4 hours 4+ hours Do you have any other comments you think might be relevant?
