![[Image: ERGO TRACK™ software]](http://www.ergotrack.com/ErgoCom.jpg)
| Name: | ___________________________ | ID: | _________ |
| Work Order#: | ___________________ | ||
| Gender: | F M | Dominant Hand: | Right Left Both |
| Standing Height: | ______ feet ______ in. |
Body Type: optional |
Lg. Med. Sm. |
| Height of footrest: Floor to bottom of back of shoe heel on footrest |
_____ (in inches) |
Weight: optional |
______ (in lbs.) |
| Height of shoe heel: | _____ (in inches) | ||
| Company: | ___________________________________ | ||
| Location: | ___________________________________ | ||
| Dept: | __________________________________ | ||
| Job: | __________________________________ | Job Code: | ____________ |
| Job Description: | __________________________________ __________________________________ __________________________________ __________________________________ |
||
| My computer is a: | desktop | laptop | both | ||
| My computer is located: | on a standard desk | on a credenza | in a corner (modular) |
||
| Time on Computer: PER DAY |
< 2 hrs. | 2 - 4 hrs. | > 4 hrs. | ||
| Time on Computer: PER SITTING |
< 2 hrs. | 2 - 4 hrs. | > 4 hrs. | ||
| My position while using keyboard & monitor is: | vertically aligned, in front of me | monitor in front, keyboard to side | keyboard in front, monitor to side | ||
| Vision Correction at Computer: | contacts | glasses | bifocals | special computer glasses | none |
| Monitor's screen is: | (15" or less) | (16" or more) | |||
| My workstation is: | adjustable | not adjustable | |||
| My chair seat height is: | adjustable | not adjustable | |||
| My chair seat depth is: | adjustable | not adjustable | |||
| My armrests are: | adjustable | not adjustable | |||
| My keyboard is on: | adjustable platform/tray | drawer | desktop | none | |
| My monitor is on: | desktop | adjustable arm/platform | stacked item(s) | ||
| Source of glare is: | none | window(s) | overhead lighting | windows & overhead lighting | |
| My mouse/mouse pad is on: | adjustable platform/tray | drawer | desktop | none | |
| My footrest is: | adjustable | not adjustable | not applicable |
| Frequently Used Shelf Height: | ________ | Vertical height from floor to upper surface of the most frequently used shelf at the workstation. |
| Workstation Height: | ________ | Vertical height from floor to the work surface or table. |
| Chair Seat Height: | ________ | Vertical height from the floor to the top of the seat surface. |
| Chair Seat Depth: | ________ | Horizontal distance between the front seat edge and the most forward part of the back rest. |
| Arm Rest Height: | ________ | Vertical height from floor to the top of the arm rest. |
| Keyboard Middle Row Height: (asdfghjkl) |
________ | Vertical height from the floor to the keyboard middle row (a,s,d,f). |
| Monitor Height: (top edge of screen/viewing area) |
________ | Vertical height from floor to upper edge of screen (glass). |
| Eye-to-Monitor Distance: | ________ | Horizontal distance (flatline) from eyes to computer monitor and/or document holder. |
| Shoulder-to-Keyboard Distance: | ________ | Horizontal distance from the person's shoulder (bony area on top) to the keyboard middle row. |
| Mouse Height: | ________ | Vertical height from floor to the top of the mouse surface. |
| Leg Minimum Height Clearance: | ________ | Vertical height from floor to the nearest surface above the knees (desktop, drawer, keyboard tray, etc). |
| Shoulder-to-Mouse Distance: | ________ | Horizontal distance from the person's shoulder (bony area on top) to the top of the mouse. |