AWC Ergonomics Assessment Form

• Conducted on

  Date

• Shift

• Job Being Performed

• Department

• Position/Station

• Product

• Location

  Select

• Person Performing Assessment

Step 1 - Assessment Category

• Picture of Work Station

  Media

• Reason For Assessment

  Select New Onset Discomfort Extensive History - Flare UP Follow UP Specialist Requested - Unknown New Assessment Post Engineering/Maintenance Project

  • New Onset Discomfort
  • Extensive History - Flare UP
  • Follow UP
  • Specialist Requested - Unknown
  • New Assessment
  • Post Engineering/Maintenance Project

Step 2 - List of Major Tasks

• Task 1

• Behavior Observed

  Select Wash Rag Elbows Out Shoulder Too High/Low Hungry Head Butts Up Twist and Shout Horizontal Distance Sit vs. Stand Bad Vibes Contact Other

  • Wash Rag
  • Elbows Out
  • Shoulder Too High/Low
  • Hungry Head
  • Butts Up
  • Twist and Shout
  • Horizontal Distance
  • Sit vs. Stand
  • Bad Vibes
  • Contact
  • Other

• Task 2

• Behavior Observed

  Select Wash Rag Elbows Out Shoulder Too High/Low Hungry Head Butts Up Twist and Shout Horizontal Distance Sit vs. Stand Bad Vibes Contact Other

  • Wash Rag
  • Elbows Out
  • Shoulder Too High/Low
  • Hungry Head
  • Butts Up
  • Twist and Shout
  • Horizontal Distance
  • Sit vs. Stand
  • Bad Vibes
  • Contact
  • Other

• Task 3

• Behavior Observed

  Select Wash Rag Elbows Out Shoulder Too High/Low Hungry Head Butts Up Twist and Shout Horizontal Distance Sit vs. Stand Bad Vibes Contact Other

  • Wash Rag
  • Elbows Out
  • Shoulder Too High/Low
  • Hungry Head
  • Butts Up
  • Twist and Shout
  • Horizontal Distance
  • Sit vs. Stand
  • Bad Vibes
  • Contact
  • Other

• Task 4

• Behavior Observed

  Select Wash Rag Elbows Out Shoulder Too High/Low Hungry Head Butts Up Twist and Shout Horizontal Distance Sit vs. Stand Bad Vibes Contact Other

  • Wash Rag
  • Elbows Out
  • Shoulder Too High/Low
  • Hungry Head
  • Butts Up
  • Twist and Shout
  • Horizontal Distance
  • Sit vs. Stand
  • Bad Vibes
  • Contact
  • Other

• Task 5

• Behavior Observed

  Select Wash Rag Elbows Out Shoulder Too High/Low Hungry Head Butts Up Twist and Shout Horizontal Distance Sit vs. Stand Bad Vibes Contact Other

  • Wash Rag
  • Elbows Out
  • Shoulder Too High/Low
  • Hungry Head
  • Butts Up
  • Twist and Shout
  • Horizontal Distance
  • Sit vs. Stand
  • Bad Vibes
  • Contact
  • Other

• Task 6

• Behavior Observed

  Select Wash Rag Elbows Out Shoulder Too High/Low Hungry Head Butts Up Twist and Shout Horizontal Distance Sit vs. Stand Bad Vibes Contact Other

  • Wash Rag
  • Elbows Out
  • Shoulder Too High/Low
  • Hungry Head
  • Butts Up
  • Twist and Shout
  • Horizontal Distance
  • Sit vs. Stand
  • Bad Vibes
  • Contact
  • Other

• Task 6

• Behavior Observed

  Select Wash Rag Elbows Out Shoulder Too High/Low Hungry Head Butts Up Twist and Shout Horizontal Distance Sit vs. Stand Bad Vibes Contact Other

  • Wash Rag
  • Elbows Out
  • Shoulder Too High/Low
  • Hungry Head
  • Butts Up
  • Twist and Shout
  • Horizontal Distance
  • Sit vs. Stand
  • Bad Vibes
  • Contact
  • Other

• Task 7

• Behavior Observed

  Select Wash Rag Elbows Out Shoulder Too High/Low Hungry Head Butts Up Twist and Shout Horizontal Distance Sit vs. Stand Bad Vibes Contact Other

  • Wash Rag
  • Elbows Out
  • Shoulder Too High/Low
  • Hungry Head
  • Butts Up
  • Twist and Shout
  • Horizontal Distance
  • Sit vs. Stand
  • Bad Vibes
  • Contact
  • Other

• Task 8

• Behavior Observed

  Select Wash Rag Elbows Out Shoulder Too High/Low Hungry Head Butts Up Twist and Shout Horizontal Distance Sit vs. Stand Bad Vibes Contact Other

  • Wash Rag
  • Elbows Out
  • Shoulder Too High/Low
  • Hungry Head
  • Butts Up
  • Twist and Shout
  • Horizontal Distance
  • Sit vs. Stand
  • Bad Vibes
  • Contact
  • Other

• Task 9

• Behavior Observed

  Select Wash Rag Elbows Out Shoulder Too High/Low Hungry Head Butts Up Twist and Shout Horizontal Distance Sit vs. Stand Bad Vibes Contact Other

  • Wash Rag
  • Elbows Out
  • Shoulder Too High/Low
  • Hungry Head
  • Butts Up
  • Twist and Shout
  • Horizontal Distance
  • Sit vs. Stand
  • Bad Vibes
  • Contact
  • Other

• Task 10

• Behavior Observed

  Select Wash Rag Elbows Out Shoulder Too High/Low Hungry Head Butts Up Twist and Shout Horizontal Distance Sit vs. Stand Bad Vibes Contact Other

  • Wash Rag
  • Elbows Out
  • Shoulder Too High/Low
  • Hungry Head
  • Butts Up
  • Twist and Shout
  • Horizontal Distance
  • Sit vs. Stand
  • Bad Vibes
  • Contact
  • Other

Step 3 - Additional Comments

• Record any comments or notes.

Step 4 - Brainstorm Solutions

• Action 1

• Improvement on.....

  Select Wash Rag Elbows Out Shoulder Too High/Low Hungry Head Butts Up Twist and Shout Horizontal Distance Sit vs. Stand Bad Vibes Contact Other

  • Wash Rag
  • Elbows Out
  • Shoulder Too High/Low
  • Hungry Head
  • Butts Up
  • Twist and Shout
  • Horizontal Distance
  • Sit vs. Stand
  • Bad Vibes
  • Contact
  • Other

• Action 2

• Improvement on.....

  Select Wash Rag Elbows Out Shoulder Too High/Low Hungry Head Butts Up Twist and Shout Horizontal Distance Sit vs. Stand Bad Vibes Contact Other

  • Wash Rag
  • Elbows Out
  • Shoulder Too High/Low
  • Hungry Head
  • Butts Up
  • Twist and Shout
  • Horizontal Distance
  • Sit vs. Stand
  • Bad Vibes
  • Contact
  • Other

• Action 3

• Improvement on.....

  Select Wash Rag Elbows Out Shoulder Too High/Low Hungry Head Butts Up Twist and Shout Horizontal Distance Sit vs. Stand Bad Vibes Contact Other

  • Wash Rag
  • Elbows Out
  • Shoulder Too High/Low
  • Hungry Head
  • Butts Up
  • Twist and Shout
  • Horizontal Distance
  • Sit vs. Stand
  • Bad Vibes
  • Contact
  • Other

• Action 4

• Improvement on.....

  Select Wash Rag Elbows Out Shoulder Too High/Low Hungry Head Butts Up Twist and Shout Horizontal Distance Sit vs. Stand Bad Vibes Contact Other

  • Wash Rag
  • Elbows Out
  • Shoulder Too High/Low
  • Hungry Head
  • Butts Up
  • Twist and Shout
  • Horizontal Distance
  • Sit vs. Stand
  • Bad Vibes
  • Contact
  • Other

• Action 5

• Improvement on.....

  Select Wash Rag Elbows Out Shoulder Too High/Low Hungry Head Butts Up Twist and Shout Horizontal Distance Sit vs. Stand Bad Vibes Contact Other

  • Wash Rag
  • Elbows Out
  • Shoulder Too High/Low
  • Hungry Head
  • Butts Up
  • Twist and Shout
  • Horizontal Distance
  • Sit vs. Stand
  • Bad Vibes
  • Contact
  • Other

Step 5 - List of Top Three Improvements

• Improvement 1

• Improvement 2

• Improvement 3

Step 6 - Sign-Off/Follow Up

• Scheduled Follow-up date:

  Date