• Ergonomic Assessment For:

  • Conducted on

  • Prepared by

  • Location
  • Workstation photos

Employee Information

  • Employee Name:

  • Job Title:

  • Department:

  • Phone number:

  • Supervisor's Name:

  • Gender:

  • Height (inches):

  • Dominate Hand:

  • Corrective Lenses:

  • Average hours spent in the office?

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

  • Does the employee perform stretching exercises?

  • Employee Comments:

Task Breakdown (% of employee's work)

  • Field work (%):

  • Face to face client interaction (%):

  • Phone usage (%):

  • Keyboard (%):

  • Mouse (%):

  • Writing/Drawing/Filing (%):

  • Time Away from Workstation (%):

  • Other (%):

  • 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?

  • Actions taken:

  • 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?

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

  • Is the keyboard tray stable?

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

  • Does the keyboard tray need to be replaced?

  • 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?

  • Add wrist rest for:

  • 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?

  • Actions taken:

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

Monitor & Source Document

  • 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?

  • Actions taken:

  • Comments on Monitor & Source Document:

Phone & Printer

  • 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?

  • Can the printer be accessed without extended reaching?

  • Actions taken:

  • Comments on phone and/or pinter:

Work Surface

  • 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?

  • Actions taken:

  • 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?

  • Actions taken:

  • 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?

  • Actions taken:

  • Comments on Environment

Evaluator Actions

  • Evaluator Actions

Summary of Recommendations

  • Recommendations:

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


  • Employee:

  • Risk Management Representative:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.