Computer Information Questionnaire

Print, fill out, and bring to your appointment if you wish to speed things up.

Name:__________________________________________ Date:___/___/_____

Please circle the appropriate answer if YES please rate from 0-10

(0 = no problem/none — 10 = the worst/a lot) in the box. ie: Yes/No 8

Word Processing Data Acquisition Data Entry Programming CAD Other

Enter the working distances from your eyes. Have a co-worker measure 3 different times.

Monitor        ___________

at, below, or above eye level?_________

Keyboard     ___________

Data            ___________

Other          ___________

Do you experience any of the following lighting problems: glare from windows, other light sources,
reflections on your monitor, or glare on your data. _____

Describe any problems you have with your current glasses or contact lenses for computer work:

_________________________________________________________________________

Enter the average number of hours you work at a computer each day. _____

How long have you been a computer operator? _____

Do you wear glasses or contact lenses for computer work?...........................................................................Yes / No

Do you experience any of the following symptoms? (Circle if Yes)

Sore or tired eyes, Itchy, burning, dry eyes, Difficulty focusing between monitor and data,
 Blurred vision at far, Blurred vision at near, Double vision, Headaches, Muscle aches
(neck, shoulder or arms), Color fringes/afterimages, Increased sensitivity to lights, Other (List)

Are you unable to adjust the screen brightness and contrast to provide screen legibility?
.......................................................................................................................................................................................................Yes/No

Are the images on your VDT screen unclear, not easy to read, unstable, or have flicker? Yes/No

Are the color of the letters and screen background visually unpleasant? ............................Yes/No

Is the VDT unit unadjustable so that it can not be tilted, swiveled and alter in height?
.......................................................................................................................................................................................................Yes/No

Is the keyboard not detachable from the VDT screen? ....................................................................Yes/No

Does your VDT unit need servicing? ..........................................................................................................................Yes/No

Are document holders unavailable when needed? ...................................................................................Yes/No

Does your chair provide poor back support and is it unadjustable in height? ...................Yes/No

Would a wrist rest useful with the keyboard? ........................................................................................Yes/No

Are you unable to control room lighting so as not to produce glare on your VDT screen? Yes/No

Would blinds or shades be useful on all windows to control light levels? .........................Yes/No

Is your monitor located near windows, so that you look directly into an unshaded window?
.......................................................................................................................................................................................................Yes/No

Would additional task lighting be needed to view source documents? .................................Yes/No

Is your working surface inadequate in size? .........................................................................................................Yes/No

Is it not possible for you to easily re-arrange the workstation? .......................................................Yes/No

Do you find yourself not maintaining normal blinking habits when working with your monitor?
......................................................................................................................................................................................................Yes/No

Do you not have yearly vision examinations? ......................................................................................................Yes/No