Charlotte-Mecklenburg Risk Management

• Ergonomic Assessment For:

• Conducted on

  Date

• Prepared by

• Location
  Address

• Workstation photos

  Media

Employee Information

• Employee Name:

• Job Title:

• Department:

• Phone number:

• Supervisor's Name:

• Gender:

  Select Male Female

  • Male
  • Female

• Height (inches):

  Select 4'8" 4'9" 4'10" 4'11" 5'0" 5'1" 5'2" 5'3" 5'4" 5'5" 5'6" 5'7" 5'8" 5'9" 5'10" 5'11" 6'0" 6'1" 6'2" 6'3" 6'4" 6'5" 6'6" 6'7" 6'8"

  • 4'8"
  • 4'9"
  • 4'10"
  • 4'11"
  • 5'0"
  • 5'1"
  • 5'2"
  • 5'3"
  • 5'4"
  • 5'5"
  • 5'6"
  • 5'7"
  • 5'8"
  • 5'9"
  • 5'10"
  • 5'11"
  • 6'0"
  • 6'1"
  • 6'2"
  • 6'3"
  • 6'4"
  • 6'5"
  • 6'6"
  • 6'7"
  • 6'8"

• Dominate Hand:

  Left

  Right

  Ambidextrous

• Corrective Lenses:

  Select None Reading Glasses Glasses Bifocals Trifocals Contact Lenses Other

  • None
  • Reading Glasses
  • Glasses
  • Bifocals
  • Trifocals
  • Contact Lenses
  • Other

• Average hours spent in the office?

  Select 4 5 6 7 8 9 10 11 12

  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12

• What is the longest period of time that work is performed without getting up for 30 seconds?

  Select 30 minutes 1 hour 1.5 hours 2 hours 2.5 3 hours 4 hours

  • 30 minutes
  • 1 hour
  • 1.5 hours
  • 2 hours
  • 2.5
  • 3 hours
  • 4 hours

• Does the employee perform stretching exercises?

  Select Yes No Informal, only when they feel tightness Physician prescribed regimen Physical Therapist prescribed regimen Exercise in the evening with regular stretching

  • Yes
  • No
  • Informal, only when they feel tightness
  • Physician prescribed regimen
  • Physical Therapist prescribed regimen
  • Exercise in the evening with regular stretching

• Employee Comments:

Task Breakdown (% of employee's work)

• Field work (%):

  Select Concurrent with other tasks Variable 0 5 10 15 20 25 30 35 40 50 55 60 65 70 75 80 85 90 95 100

  • Concurrent with other tasks
  • Variable
  • 0
  • 5
  • 10
  • 15
  • 20
  • 25
  • 30
  • 35
  • 40
  • 50
  • 55
  • 60
  • 65
  • 70
  • 75
  • 80
  • 85
  • 90
  • 95
  • 100

• Face to face client interaction (%):

  Select Concurrent with other tasks Variable 0 5 10 15 20 25 30 35 40 50 55 60 65 70 75 80 85 90 95 100

  • Concurrent with other tasks
  • Variable
  • 0
  • 5
  • 10
  • 15
  • 20
  • 25
  • 30
  • 35
  • 40
  • 50
  • 55
  • 60
  • 65
  • 70
  • 75
  • 80
  • 85
  • 90
  • 95
  • 100

• Phone usage (%):

  Select Concurrent with other tasks Variable 0 5 10 15 20 25 30 35 40 50 55 60 65 70 75 80 85 90 95 100

  • Concurrent with other tasks
  • Variable
  • 0
  • 5
  • 10
  • 15
  • 20
  • 25
  • 30
  • 35
  • 40
  • 50
  • 55
  • 60
  • 65
  • 70
  • 75
  • 80
  • 85
  • 90
  • 95
  • 100

• Keyboard (%):

  Select Concurrent with other tasks Variable 0 5 10 15 20 25 30 35 40 50 55 60 65 70 75 80 85 90 95 100

  • Concurrent with other tasks
  • Variable
  • 0
  • 5
  • 10
  • 15
  • 20
  • 25
  • 30
  • 35
  • 40
  • 50
  • 55
  • 60
  • 65
  • 70
  • 75
  • 80
  • 85
  • 90
  • 95
  • 100

• Mouse (%):

  Select Concurrent with other tasks Variable 0 5 10 15 20 25 30 35 40 50 55 60 65 70 75 80 85 90 95 100

  • Concurrent with other tasks
  • Variable
  • 0
  • 5
  • 10
  • 15
  • 20
  • 25
  • 30
  • 35
  • 40
  • 50
  • 55
  • 60
  • 65
  • 70
  • 75
  • 80
  • 85
  • 90
  • 95
  • 100

• Writing/Drawing/Filing (%):

  Select Concurrent with other tasks Variable 0 5 10 15 20 25 30 35 40 50 55 60 65 70 75 80 85 90 95 100

  • Concurrent with other tasks
  • Variable
  • 0
  • 5
  • 10
  • 15
  • 20
  • 25
  • 30
  • 35
  • 40
  • 50
  • 55
  • 60
  • 65
  • 70
  • 75
  • 80
  • 85
  • 90
  • 95
  • 100

• Time Away from Workstation (%):

  Select Concurrent with other tasks Variable 0 5 10 15 20 25 30 35 40 50 55 60 65 70 75 80 85 90 95 100

  • Concurrent with other tasks
  • Variable
  • 0
  • 5
  • 10
  • 15
  • 20
  • 25
  • 30
  • 35
  • 40
  • 50
  • 55
  • 60
  • 65
  • 70
  • 75
  • 80
  • 85
  • 90
  • 95
  • 100

• Other (%):

  Select Concurrent with other tasks Variable 0 5 10 15 20 25 30 35 40 50 55 60 65 70 75 80 85 90 95 100

  • Concurrent with other tasks
  • Variable
  • 0
  • 5
  • 10
  • 15
  • 20
  • 25
  • 30
  • 35
  • 40
  • 50
  • 55
  • 60
  • 65
  • 70
  • 75
  • 80
  • 85
  • 90
  • 95
  • 100

• Concurrent work description that causes % to be > 100:

Chair

• Can the chair height be adjusted so the worker's thighs are parallel to the floor?

  Yes

  No

  N/A

• Can the lumbar support be adjusted so that it fits into the worker's lumbar region on their back?

  Yes

  No

  N/A

• Does the backrest recline have a lockout to support the worker in an upright posture?

  Yes

  No

  N/A

• Can the armrests be adjusted to just below the elbow of the worker?

  Yes

  No

  N/A

• Can the seat pan depth be adjusted to allow three fingers width between the back of the worker's knee and the front of the seat pan?

  Yes

  No

  N/A

• Do the armrests allow the worker to get close enough to the workstation?

  Yes

  No

  N/A

• Actions taken:

  Select Adjusted height of the chair Adjusted lumbar support Adjusted arm rests Adjusted seat pan depth Reevaluate chair during follow up assessment Recommend an alternate chair

  • Adjusted height of the chair
  • Adjusted lumbar support
  • Adjusted arm rests
  • Adjusted seat pan depth
  • Reevaluate chair during follow up assessment
  • Recommend an alternate chair

• Comments on Chair:

Keyboard Tray, Keyboard & Pointing Device

• If the chair needs to be raised to position the worker better with respect to the keyboard and pointing device, is there a foot rest available to keep the worker's thighs parallel to the floor?

  Yes

  No

  N/A

• Is there an articulating keyboard tray installed at the workstation?

  Yes

  No

• Is the keyboard tray stable?

  Yes

  No

  N/A

• Is the keyboard tray large enough for both the keyboard and the pointing device?

  Yes

  No

  N/A

• Does the keyboard tray need to be replaced?

  Yes

  No

  N/A

• Does the angle of the keyboard allow the wrists to be straight?

  Yes

  No

  N/A

• Is the employee having symptoms in the hands/wrists/elbows?

  Yes

  No

• Select Recommend providing a vertical mouse Recommend providing an ergonomic keyboard

  • Recommend providing a vertical mouse
  • Recommend providing an ergonomic keyboard

• Does the mouse fit the hand?

  Yes

  No

• Is the pointing device located next to the keyboard?

  Yes

  Yes, but the keyboard and mouse are on the desk top causing the employee to reach for them

  Yes, but the mouse tray is unstable/unusable

  No

• Is a wrist rest, or padding, available to protect against hand or forearm contact with sharp or hard edges?

  Yes

  No

• Add wrist rest for:

  Select Keyboard Pointing Device

  • Keyboard
  • Pointing Device

• Is the employee required to lean against the wrist rest to perform tasks?

  Yes

  No

• If a laptop computer is used, are an external keyboard and pointing device provided?

  Yes

  No

  N/A

• Actions taken:

  Select Adjusted keyboard tray Adjusted location of mouse Adjusted location of keyboard If keyboard/mouse on desk top, trained to slide all the way under the desk Recommend providing a vertical mouse Recommend providing an ergonomic keyboard Recommend installing an adjustable keyboard tray

  • Adjusted keyboard tray
  • Adjusted location of mouse
  • Adjusted location of keyboard
  • If keyboard/mouse on desk top, trained to slide all the way under the desk
  • Recommend providing a vertical mouse
  • Recommend providing an ergonomic keyboard
  • Recommend installing an adjustable keyboard tray

• Comments on Keyboard Tray, Keyboard, and Pointing Device:

Monitor & Source Document

• If a laptop computer is used, is an external monitor provided?

  Yes

  No

  N/A

• Is the monitor located in front of the employee?

  Yes

  No

• 2 monitors

  1 monitor & laptop screen

  1 monitor

• Is the monitor approximately an arm's length away from the worker?

  Yes

  No

• Is the monitor set at a height so that the top row of the characters on the screen is even with the seated eye height of the user?

  Yes

  No

• Is the font size, screen contrast and/or image quality in print and on the monitor acceptable?

  Yes

  No

• If a document holder is used, is the document holder located adjacent to the monitor?

  Yes

  No

  N/A

• Actions taken:

  Select Moved monitor(s) in front of employee Repositioned the monitor(s) an arm's length away from the employee Raised height of the monitor(s) Lowered height of the monitor(s) Adjusted location of the document holder Adjusted the resolution of the monitor Recommend providing an adjustable document holder Recommend adjusting location/height of monitor(s) once equipment is provided

  • Moved monitor(s) in front of employee
  • Repositioned the monitor(s) an arm's length away from the employee
  • Raised height of the monitor(s)
  • Lowered height of the monitor(s)
  • Adjusted location of the document holder
  • Adjusted the resolution of the monitor
  • Recommend providing an adjustable document holder
  • Recommend adjusting location/height of monitor(s) once equipment is provided

• Comments on Monitor & Source Document:

Phone & Printer

• Is the phone located on the same side as the hand that is used to answer it?

  Yes

  No

  N/A

• Handset/Headset:

  Handset

  Headset

• Can the phone be answered without extended reaching?

  Yes

  No

  N/A

• Does the employee talk on the phone without cradling it on their shoulder?

  Yes

  No

  N/A

• Does the employee utilize speaker phone or a headset while participating in conference calls?

  Yes

  No

  N/A

• Does the employee have a printer?

  Yes

  No

  N/A

• Can the printer be accessed without extended reaching?

  Yes

  No

  It is a community printer is not located at their work station

• Actions taken:

  Select Moved the phone to the same side as the hand that is used to answer it Moved phone closer to the employee Moved the location of the printer to within an arm's reach of the employee

  • Moved the phone to the same side as the hand that is used to answer it
  • Moved phone closer to the employee
  • Moved the location of the printer to within an arm's reach of the employee

• Comments on phone and/or pinter:

Work Surface

• Is there sufficient space for all equipment and accessories?

  Yes

  No

• Are frequently used equipment and supplies within an arm's reach?

  Yes

  No

• Is the work surface height adjustable?

  Yes

  No

• Cube desk that is only adjustable up

  Sit/Stand workstation

  Fully adjustable desk

• Actions taken:

  Select Reorganized equipment Reorganized furniture Adjusted work surface height Reevaluate the work surface height during the follow up assessment

  • Reorganized equipment
  • Reorganized furniture
  • Adjusted work surface height
  • Reevaluate the work surface height during the follow up assessment

• Comments on Work Surface:

Workspace

• Is the CPU in a location that does not interfere with positioning of the the employee at the workstation?

  Yes

  No

• Can the employee move about the workspace easily, free from equipment or supplies obstructing movement?

  Yes

  No

• Is there adequate leg clearance (height, width, depth)?

  Yes

  No

• Is there sufficient storage and filing room to keep the work area free from clutter?

  Yes

  No

• Actions taken:

  Select Repositioned CPU Reorganized work space

  • Repositioned CPU
  • Reorganized work space

• Comments on Work Space

Environment

• Is lighting adequate for all tasks?

  Yes

  No

• Is the monitor screen free of glare from overhead lighting?

  Yes

  No

• Are monitors free from glare from windows?

  Yes

  No

• Employee works in a cube (no windows)

  Employee works in an internal office with no windows

  Employee has a window, but adequate shading for the monitors

  Move monitor to eliminate glare

  Provide blinds, shades, or window tint

• Is the workstation climate acceptable?

  Yes

  No

• Actions taken:

  Select Reduced overhead lighting Changed location of monitor(s) Adjusted blinds, curtains, etc. Adjusted the work station climate

  • Reduced overhead lighting
  • Changed location of monitor(s)
  • Adjusted blinds, curtains, etc.
  • Adjusted the work station climate

• Comments on Environment

Evaluator Actions

• Evaluator Actions

  Select Provided reference material for employee to properly adjust their workstation (chair, keyboard, mouse, monitor, etc.). Provided training on proper neutral ergonomic postures. Recommended the employee request a follow-up assessment once recommendations are met.

  • Provided reference material for employee to properly adjust their workstation (chair, keyboard, mouse, monitor, etc.).
  • Provided training on proper neutral ergonomic postures.
  • Recommended the employee request a follow-up assessment once recommendations are met.

Summary of Recommendations

• Recommendations:

  Select Provide an alternate chair with adjustable height, arm rests (height & width), lumbar support, & seat pan depth. Change chair cylinder to a "low height" cylinder. Adjust chair once keyboard tray is installed. Install an adjustable keyboard tray (wide enough for a mouse as well). Provide an adjustable foot rest. Provide a vertical mouse Provide an ergonomic style keyboard. Repair keyboard tray Add wrist rest for keyboard (if not on keyboard tray). Add wrist rest for mouse (if not on keyboard tray). Provide an external monitor. Provide an external mouse. Provide an external keyboard. Move monitor(s) directly in front of employee. Move monitor(s) to within an arm's length of the employee. Raise height of monitor(s). Lower height of monitor(s). Adjust the location/height of monitor(s) once equipment is provided Provide an adjustable document holder. Change resolution/size of text of the monitor. Move phone to dominate hand side within an arm's length. Provide a telephone headset. Adjust height of the work surface. Provide a sit/stand workstation that promotes a healthy balance of sitting/standing/walking. 70% sitting, 25% standing, and 5% walking Provide an anti-fatigue mat Reevaluate the chair during the follow up assessment. Reevaluate the pointing device during the follow up assessment. Reevaluate the keyboard during the follow up assessment. Reevaluate the work surface height during the follow up assessment. Reevaluate the need for a keyboard tray during the follow up assessment. See additional comments:

  • Provide an alternate chair with adjustable height, arm rests (height & width), lumbar support, & seat pan depth.
  • Change chair cylinder to a "low height" cylinder.
  • Adjust chair once keyboard tray is installed.
  • Install an adjustable keyboard tray (wide enough for a mouse as well).
  • Provide an adjustable foot rest.
  • Provide a vertical mouse
  • Provide an ergonomic style keyboard.
  • Repair keyboard tray
  • Add wrist rest for keyboard (if not on keyboard tray).
  • Add wrist rest for mouse (if not on keyboard tray).
  • Provide an external monitor.
  • Provide an external mouse.
  • Provide an external keyboard.
  • Move monitor(s) directly in front of employee.
  • Move monitor(s) to within an arm's length of the employee.
  • Raise height of monitor(s).
  • Lower height of monitor(s).
  • Adjust the location/height of monitor(s) once equipment is provided
  • Provide an adjustable document holder.
  • Change resolution/size of text of the monitor.
  • Move phone to dominate hand side within an arm's length.
  • Provide a telephone headset.
  • Adjust height of the work surface.
  • Provide a sit/stand workstation that promotes a healthy balance of sitting/standing/walking. 70% sitting, 25% standing, and 5% walking
  • Provide an anti-fatigue mat
  • Reevaluate the chair during the follow up assessment.
  • Reevaluate the pointing device during the follow up assessment.
  • Reevaluate the keyboard during the follow up assessment.
  • Reevaluate the work surface height during the follow up assessment.
  • Reevaluate the need for a keyboard tray during the follow up assessment.
  • See additional comments:

• Once recommendations have been met, please schedule a follow up assessment to ensure proper equipment set up as well as re-evaluation of symptoms.

Signatures

• Employee:

  Sign

• Risk Management Representative:

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