UMB Environmental Health and Safety

University of Maryland Baltimore

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Contact:
Environmental Health
and Safety
714 W. Lombard Street
Baltimore, MD 21201
410-706-7055
Fax 410-706-8212

Ergonomic Survey Request Form
Contact: Nick Wellnitz at 6-3490

Name:	First Last
Supervisor Name:	First Last
Date Submitted:
Date Selected for Survey:	i.e., (02/05/05)
Email:
Location of Survey:	Building Room
Workstation Description:
Discomfort Area:	head neck forearm hand shoulders lower back multiple (Check all which apply)
Comments:
EHS also recommends visiting the following OSHA website that delineates the proper ergonomic workstation setup. http://www.osha.gov/SLTC/etools/computerworkstations/index.html

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