Please fill out the following survey questions. Your answers will analysed and a FREE Ergonomic Gap report of your program’s effectiveness will be sent to you.

 

Your name

 

Company

 

Email

 

Phone

 

How many employees do you have?

1-9
10-249
250-2499
2500-10,000
More than 10,000

 

Number of computer users?

1-9
10-249
250-2499
2500-10,000
More than 10,000

 

Number of ergonomic injuries per year?

 

Most common ergonomic injury?

 

Do you have an Ergonomics Process in place?

Yes
No
N/A
Don't Know

 

Do you have a designated ergonomics person running the program?

Yes
No
N/A
Don't Know

 

Is a Consultant running your program?

Yes
No
N/A
Don't Know

 

Is your Insurance company managing your program?

Yes
No
N/A
Don't Know

 

Do you have an ergonomics committee?

Yes
No
N/A
Don't Know

 

Is the Facility department involved in the committee?

Yes
No
N/A
Don't Know

 

Is the Information Technology department involved in the committee?

Yes
No
N/A
Don't Know

 

Is the HR department involved in the committee?

Yes
No
N/A
Don't Know

 

Is the Engineering department involved in the committee?

Yes
Know
N/A
Don't Know

 

Is the Safety department involved in the committee?

Yes
No
N/A
Don't Know

 

Is the Procurement department involved in the committee?

Yes
No
N/A
Don't Know

 

How often do you have meetings?

Weekly
Monthly
Less Frequently
N/A
Don't Know

 

Are you currently using Ergonomics software?

Yes
No
N/A
Don't Know

 

Does your Ergonomics program have an allocated budget?

Yes
No
N/A
Don't Know

 

Has your company received any OSHA violations for ergonomics in the past year?

Yes
No
N/A
Don't Know

 

Do you have a system in place to track and measure results?

Yes
No
N/A
Don't Know