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Ergonomics webinar participation

We are seeking photo submissions of patients' workstations at home to be assessed by Dr. Kuserk during our May 19 webinar! (Note that we cannot share all of them, and will likely select 3-5 total.)

By submitting the photo, you agree that you are willing to have it and your first name shared during the webinar.
  • You can be in the photo or not. (Being in the photo will help Dr. Kuserk better assess your positioning, but it's not required.)
  • Please do not have any personal information visible in the photo.
  • If you are in the photo, we may blur your face so you are not recognizable.
If you have trouble with this form, email emily@uspainfoundation.org.
1. Please provide your contact information.
This question requires a valid email address.
2. By submitting this photo, I agree and acknowledge that U.S. Pain Foundation has permission to share it and my first name only during the webinar event on May 19, which is a public event that will be recorded and shared on U.S. Pain's website, newsletter, and social media.

I also understand and explicitly acknowledge that the internet allows for wide sharing and forwarding of information, and that U.S. Pain Foundation cannot control all re-disclosure of information.

  *This question is required.
3. Please upload a photo of your workstation. Reminder: you can be in the photo or not; please do not have personal information visible in the shot; if your face is visible, we may blur it. Note that the file size limit is 10 MB. *This question is required.
5. If your photo is selected to be shared, are you comfortable with us also sharing your response to #4? *This question is required.