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Ergonomic Excellence Request Form
First Name
Last Name
Email
Street Address
City
State
Postal / Zip code
Country
Phone
Job Title
Height
Dominate hand
Right
Left
Discomfort (check all that apply)
Neck
Right Shoulder
Left Shoulder
Right Hand/Wrist
Left Hand/Wrist
Right Arm
Left Arm
Right Forearm
Left Forearm
Fingers
Right Elbow
Left Elbow
Upper Back
Lower Back
Right Leg
Left Leg
Right Foot
Left Foot
Hips
Eyes
Head
Please provide a brief description of your discomfort
Please include one or two photos of the employee at their work station. Please be sure to include the chair, desk, keyboard, monitor, etc. If the employee is unable to be in the photo just a photo of the equipment will suffice.
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