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Pre-Assessment Form

If you would like us to assess your working practices for areas of ergonomic improvement, please complete the form below.

Who the assessment is for

Your name*

Company name

Address 1*

Address 2

Address 3

City*

Postcode*

Contact telephone*

Extension

Email*

Sex

Age*

Height*

Weight*

Who is responsible

Manager's name*

Title*

Telephone number*

Direct line

Email*

Assessment Measurements

A: Buttock to top of shoulder (cm)

B: Buttock to centre of lumar curve (cm)

C: Under elbow to buttock (cm)

D: Back of buttock to behind knee (cm)

E: Under knee to base of foot in shoes (cm)

F: Height of desk to top of surface (cm)

G: Width across hips (cm)

Workstation Information / Working Practices

Desk shape

Computer type

If you wear glasses, which type?

Dominant hand

Are you a touch typist?

Which hand do you use your mouse with?

Working Hours

How many hours do you work in a day?

Maxmimum time spent in front of PC

Percentage of time doing the following (total being 100%):

Computer (%)

Writing (%)

Reading (%)

Telephone (%)

Meetings (%)

Away from desk (%)

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