Remote Home Office Ergonomic Evaluation Completion of the checklist below will help us to determine if your home office workstation is properly set up. At the bottom of this online form, we request you upload two (2) pictures of yourself seated or standing at your desk (working) – with as much of your body and workstation in the shot as possible. (You may also email pictures to ErgonomicWorks with your full name and "HOME office ergonomic evaluation" in the subject line.) If we need any clarification, we will call or email you directly. We look forward to working with you! Name: Phone Number: Email Address: Job Title: Type of Request Ergonomic workstation evaluation Seating evaluation Information and demonstration of ergonomic workstation equipment In a paragraph, explain what type of work you do: If you have a confirmed medical diagnosis from a doctor (that you feel relates to your work) please provide this: Do you have pain or discomfort associated with sitting or standing at your desk (or workstation)? If so, please explain in detail. How many hours per day on average do you spend sitting or standing at your desk? How many times per day, on average, do you speak on the phone while at work? Do you use braces or other prescribed devices (Bluetooth, headsets, etc.)? What is your: Height: Weight: Age: What type of lighting (e.g., overhead fluorescent, desk lamps, direct sunlight) do you have at your workstation (be specific as possible). How many hours per day do you spend at the computer outside of work (i.e. using a home PC or lap-top)? Do you use PC or lap-top at your workstation? PC LAPTOP Please list any other chronic medical conditions or accidents you have had in the last twenty (20) years. Do you sit directly in front of your screen? YES NO Can you view the monitor without seeing glare on the screen? YES NO Are your feet supported on the floor? YES NO Are your hips against the back of the chair? YES NO Is the chair backrest adjusted to support your back? YES NO Is your seat long enough and wide enough to support your hips and thighs? YES NO Please type any additional information in box below (optional): Please upload your ergonomic picture here. Almost finished! When you click the Submit button below, you’ll be directed to a secure payment page. Again, the cost of an Ergonomicworks remote ergonomics evaluation of your HOME office is $200.