Audit
Employee Name:
Job Title:
Department:
Phone number:
Supervisor's Name:
- Male
- Female
- 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:
- None
- Reading Glasses
- Glasses
- Bifocals
- Trifocals
- Contact Lenses
- Other
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 30 minutes
- 1 hour
- 1.5 hours
- 2 hours
- 2.5
- 3 hours
- 4 hours
- Yes
- No
- Informal, only when they feel tightness
- Physician prescribed regimen
- Physical Therapist prescribed regimen
- Exercise in the evening with regular stretching
Employee Comments:
- 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 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 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 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:
Can the chair height be adjusted so the worker's thighs are parallel to the floor?
Can the lumbar support be adjusted so that it fits into the worker's lumbar region on their back?
Does the backrest recline have a lockout to support the worker in an upright posture?
Can the armrests be adjusted to just below the elbow of the worker?
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?
Do the armrests allow the worker to get close enough to the workstation?
- 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:
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?
Is there an articulating keyboard tray installed at the workstation?
Does the angle of the keyboard allow the wrists to be straight?
Is the employee having symptoms in the hands/wrists/elbows?
Does the mouse fit the hand?
Is the pointing device located next to the keyboard?
Is a wrist rest, or padding, available to protect against hand or forearm contact with sharp or hard edges?
Is the employee required to lean against the wrist rest to perform tasks?
If a laptop computer is used, are an external keyboard and pointing device provided?
- 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:
If a laptop computer is used, is an external monitor provided?
Is the monitor located in front of the employee?
Is the monitor approximately an arm's length away from the worker?
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?
Is the font size, screen contrast and/or image quality in print and on the monitor acceptable?
If a document holder is used, is the document holder located adjacent to the monitor?
- 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:
Is the phone located on the same side as the hand that is used to answer it?
Handset/Headset:
Can the phone be answered without extended reaching?
Does the employee talk on the phone without cradling it on their shoulder?
Does the employee utilize speaker phone or a headset while participating in conference calls?
Does the employee have a printer?
- 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:
Is there sufficient space for all equipment and accessories?
Are frequently used equipment and supplies within an arm's reach?
Is the work surface height adjustable?
- Reorganized equipment
- Reorganized furniture
- Adjusted work surface height
- Reevaluate the work surface height during the follow up assessment
Comments on Work Surface:
Is the CPU in a location that does not interfere with positioning of the the employee at the workstation?
Can the employee move about the workspace easily, free from equipment or supplies obstructing movement?
Is there adequate leg clearance (height, width, depth)?
Is there sufficient storage and filing room to keep the work area free from clutter?
- Repositioned CPU
- Reorganized work space
Comments on Work Space
Is lighting adequate for all tasks?
Is the monitor screen free of glare from overhead lighting?
Are monitors free from glare from windows?
Is the workstation climate acceptable?
- Reduced overhead lighting
- Changed location of monitor(s)
- Adjusted blinds, curtains, etc.
- Adjusted the work station climate
Comments on Environment
- 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.
- 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.