HomeBusiness, Finance, & TechnologyAdministrative ServicesRisk ManagementWorkstation Evaluation Request Workstation Evaluation Request Workstation Assessment Request Name* First Last What department do you work in?Supervisor's Name* First Last Your supervisor will receive a copy of the final assessment.What is your level of activity throughout the day?*Sedentary- sitting for most of the work dayLightly Active- sitting for most of the work day, but moving around at least once an hourActive- equal amount of sitting and movingVery Active- very little sitting, on your feet for most of the work dayDoes your current job require you to regularly lift more than 25 pounds or bend/stoop frequently?*YesNoPlease indicate where you have pain or discomfort while at your workstation.* Head/headaches Neck/shoulders Elbows Hands/wrists Lower back Upper back Hips Knees Feet Have you been seen by a doctor or the Faculty/Staff Health & Wellness Clinic because of this discomfort?YesNoWhat are the specific concerns with your workstation? Is there anything the assessor should know prior to the assessment?Assessment Scheduling*Second Wednesday of the month, 2-4pmThird Thursday of the month, 9-11amLast Friday of the month, 2-4pmAssessments occur weekly on a rotating schedule. Please indicate which time frame is best for you. If you are not available during any of these times, we will reach out to schedule an assessment directly.