Ergo Suggestion Form

Copied from USPS form

ERGONOMIC RISK REDUCTION PROCESS, Ft. Laud P&DC

Ergonomic Suggestions

Help Us...Help You...

Instructions: Complete and return to the ERRP drop box.

Name (optional): _______________ Date:_______ Tour ____

Time Submitted:___________

Do you want a Core Team member to talk with you? __Yes ___ No Your days off?______

Normal job/task assignment: ____________________________________________________

Task performed when concern is/was noticed: ____________

___________________________________________________

Ergonomic Concern [Write your concern below and check the boxes to help describe it]:

___________________________________________________

1. Awkward Postures? 2. Excessive Forces?

____Bent/twisted back ____Grasp/pinch forces

____Bent wrists ____Push/Pull

____Elbows from body ____Lift (back)

____Bent neck ____Carry (back/arms)

3. Not in easy reach? 4. Not at right height?

____At arm's length ____Above shoulders

____Beyond arm's length ____Below knees

____Equip-to-equip heights

5. Repetitive Motions? 6. Fatiguing Static Loads

____Back ____Bending (back)

____Hands/fingers ____Bent (other body part)

____Elbows ____Grip (hands)

____Shoulders ____Elbows from body (arms)

7. Pressure Points? 8. Poor clearance?

____Hands (tool grip) ____Bump/hit body against

____Arms ____Can't see

____Knees

____Feet

9. Move & Stretch? 10. Environment?

____Standing in one place ____Vibration (Hand/WB)

____Constant sitting ____Temp extremes (ambient)

____Lighting (too dark/bright)

____Noise

Suggestions [Specific improvement idea to reduce or resolve the ergonomic concern]:

_________________________________________________________

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