Title Page
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Conducted on
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Prepared by
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Location
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INSTRUCTIONS
1. Type in your responses on the blank fields below. Answer "SAFE" or "AT RISK" on the questions.
2. Add photos and notes by clicking on the paperclip icon
3. To add a Corrective Measure click on the paperclip icon then "Add Action", provide a description, assign to a member, set priority, and due date
4. Complete audit by providing digital signature
5. Share your report by exporting as PDF, Word, Excel or Web Link
DSE Workstation Assessment
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User Name
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Job Title
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Location
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DSE Assessor Name
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Date
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Managers Name
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Computer Type
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Way of Working
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Duration of Use
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Number of Screens
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Right or Left Handed
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Hours Worked
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Comments
Risks
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Display Screen
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Current
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Risk Rating
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Keyboard
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Current
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Risk Rating
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Mouse
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Current
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Risk Rating
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Regular Breaks
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Current
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Risk Rating
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Chair
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Current
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Risk Rating
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Desk
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Current
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Risk Rating
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Environment
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Current
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Risk Rating
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Eyesight
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Current
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Risk Rating
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Medical Issues
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Current
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Risk Rating
Sign Off
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Name & Signature
