Remote Ergonomic Workspace Assessment & Design Form
1) Please provide at least 2 photos of the client in their workspace while at work.
2) One photo should be from the side, one should be from the rear/overhead angle.
3) The more we can see the better, so wide shots of the entire workspace are preferred.
Examples of effective workspace photographs.
4) Email pictures to: customerservice@summitergo.com
5) Based on the photographs we may need to ask you for a few basic measurements. Please
include the best way to contact you in your email.
Remote Ergonomic Workspace
Assessment & Design Form
F
A
B
E
C
D
A. Sitting Eye Height
in
B. Sitting Elbow Height
in
C. Sitting Surface Height
in
D. Popliteal Height
(If diff than C above)
in
E. Worksurface Height
in
F. Sitting Screen Distance
in
G. Standing Eye Height
in
H. Standing Elbow Height
in
I. Screen Distance
in
J. Stand Worksurface Ht
in
Existing Workstation
X
G
H
J
X: ______ in
X
X
Y
Y
I
Y
Y: ______ in
Z: ______ in
V
W
Z
V: ______ in
W
Z
Corner Style (if desk is not a rectangle)
W: ______in
Stand-alone
Overhead Storage
Multiple Monitors Qty _________________
Cubicle
Pedestal Storage
Old Adjustable Ht Unit
Wood / Laminate
Pencil Drawer
Grommet Holes
Steel Desk
Keyboard Tray
Distance to Nearest Outlet _______________
Type ____________
Location _______________
Rear Edge of Desk
Profile/Overhang
T
T: ______ in
Copyright © Summit Ergonomics 2016
Remote Ergonomic Workspace
Assessment & Design Form
1. Worker Initials ________ 2. Height (in) _______ 3. Approx Weight (lb) _______ 4. Age _______ 5. Dominance c L c R
6. Goal of the Assessment _____________________________________________________________________________________________
7. Chief Complaint(s) _________________________________________________________________________________________________
8. Job Title _________________________________________
9. Most Frequent Job Duties & Approx Time Spent Doing Each
10. Approximate Time Spent….
________________________________
_______ min / hr
Sitting
_______ min / hr
________________________________
_______ min / hr
Standing _______ min / hr
________________________________
_______ min / hr
Perching _______ min / hr
________________________________
_______ min / hr
Kneeling _______ min / hr
________________________________
_______ min / hr
Reaching _______ min / hr
11. Ergonomic Interventions Already Tried (if any) _________________________________________________________________________
12. Touch Typist c Y c N
13. Preferred Mousing
cL c R
14. Type / Input from Documents
cY cN
Copyright © Summit Ergonomics 2016
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