DUKE ERGONOMICS
STUDENT WORKSTATION EVALUATION
REQUEST
P L E A S E F A X O R E M A I L T H I S F O R M T O:
TO:
FAX:
Duke Ergonomics Division
(919) 286-6763
PHONE NUMBER:
EMAIL::
919-668-ERGO
ergonomics@mc.duke.edu
Name:
Phone number:
Email address:
Undergraduate Student
Graduate Student
Requested by:
Self (if a Duke Employee)
Student Health (indicate Provider)
If also a Duke employee, please complete the following below:
Duke Unique ID:
Department:
Work Number:
Job Title:
If the work site is to be evaluated, complete the following below:
Supervisor/Manager Name:
Supervisor/Manager Phone:
Supervisor/Manager Email:
Reason for Request or Other Comments:
On a scale of 0-10 with 0 being the lowest and 10 highest amount of discomfort,
please enter the number you would rate your current level.
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