Information
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Ergonomic Assessment For:
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Conducted on
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Prepared by
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Location
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Workstation photos
Employee Information
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Employee Name:
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Job Title:
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Department:
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Phone number:
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Supervisor's Name:
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Gender:
- Male
- Female
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Height (inches):
- 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"
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Dominate Hand:
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Corrective Lenses:
- None
- Reading Glasses
- Glasses
- Bifocals
- Trifocals
- Contact Lenses
- Other
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Average hours spent in the office?
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
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What is the longest period of time that work is performed without getting up for 30 seconds?
- 30 minutes
- 1 hour
- 1.5 hours
- 2 hours
- 2.5
- 3 hours
- 4 hours
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Does the employee perform stretching exercises?
- Yes
- No
- Informal, only when they feel tightness
- Regular stretching and/or activity during the work day
- Physician prescribed regimen
- Physical Therapist prescribed regimen
- Exercise in the evening with regular stretching
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Employee Comments:
Task Breakdown (% of employee's work)
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Field work (%):
- Concurrent with other tasks
- Variable
- 0
- 5
- 10
- 15
- 20
- 25
- 30
- 35
- 40
- 45
- 50
- 55
- 60
- 65
- 70
- 75
- 80
- 85
- 90
- 95
- 100
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Face to face client interaction (%):
- Concurrent with other tasks
- Variable
- 0
- 5
- 10
- 15
- 20
- 25
- 30
- 35
- 40
- 45
- 50
- 55
- 60
- 65
- 70
- 75
- 80
- 85
- 90
- 95
- 100
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Phone usage (%):
- Concurrent with other tasks
- Variable
- 0
- 5
- 10
- 15
- 20
- 25
- 30
- 35
- 40
- 45
- 50
- 55
- 60
- 65
- 70
- 75
- 80
- 85
- 90
- 95
- 100
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Keyboard (%):
- Concurrent with other tasks
- Variable
- 0
- 5
- 10
- 15
- 20
- 25
- 30
- 35
- 40
- 45
- 50
- 55
- 60
- 65
- 70
- 75
- 80
- 85
- 90
- 95
- 100
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Mouse (%):
- Concurrent with other tasks
- Variable
- 0
- 5
- 10
- 15
- 20
- 25
- 30
- 35
- 40
- 45
- 50
- 55
- 60
- 65
- 70
- 75
- 80
- 85
- 90
- 95
- 100
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Writing/Drawing/Filing (%):
- Concurrent with other tasks
- Variable
- 0
- 5
- 10
- 15
- 20
- 25
- 30
- 35
- 40
- 45
- 50
- 55
- 60
- 65
- 70
- 75
- 80
- 85
- 90
- 95
- 100
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Time Away from Workstation (%):
- Concurrent with other tasks
- Variable
- 0
- 5
- 10
- 15
- 20
- 25
- 30
- 35
- 40
- 45
- 50
- 55
- 60
- 65
- 70
- 75
- 80
- 85
- 90
- 95
- 100
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Other (%):
- Concurrent with other tasks
- Variable
- 0
- 5
- 10
- 15
- 20
- 25
- 30
- 35
- 40
- 45
- 50
- 55
- 60
- 65
- 70
- 75
- 80
- 85
- 90
- 95
- 100
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Concurrent work description that causes % to be > 100:
Chair
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Can the chair height be adjusted so the worker's thighs are parallel to the floor?
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Can the lumbar support be adjusted so that it fits into the worker's lumbar region on their back?
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Does the backrest recline have a lockout to support the worker in an upright posture?
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Can the armrests be adjusted to just below the elbow of the worker?
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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?
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Do the armrests allow the worker to get close enough to the workstation?
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Actions taken:
- Adjusted height of the chair
- Adjusted lumbar support
- Adjusted arm rests
- Adjusted recline tension
- Adjusted seat pan depth
- Reevaluate chair during follow up assessment
- Recommend an alternate chair
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Comments on Chair:
Keyboard Tray, Keyboard & Pointing Device
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If the chair needs to be raised to position the worker better with respect to the keyboard and pointing device, is there a footrest available to keep the worker's thighs parallel to the floor?
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Is there an articulating keyboard tray installed at the workstation?
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Is the keyboard tray stable?
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Is the keyboard tray large enough for both the keyboard and the pointing device?
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Does the keyboard tray need to be replaced?
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Does the angle of the keyboard allow the wrists to be straight?
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Is the employee having symptoms in the hands/wrists/elbows?
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- Recommend providing a vertical mouse
- Recommend providing an ergonomic keyboard
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Does the mouse fit the hand?
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Is the pointing device located next to the keyboard?
- Yes
- Yes, but the keyboard and mouse are on the desktop causing the employee to reach for them
- Yes, but the mouse tray is unstable/unusable
- No
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Is a wrist rest, or padding, available to protect against hand or forearm contact with sharp or hard edges?
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Add wrist rest for:
- Keyboard
- Pointing Device
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Is the employee required to lean against the wrist rest to perform tasks?
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If a laptop computer is used, are an external keyboard and pointing device provided?
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Actions taken:
- 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
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Comments on Keyboard Tray, Keyboard, and Pointing Device:
Monitor & Source Document
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If a laptop computer is used, is an external monitor provided?
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Is the monitor located in front of the employee?
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Is the monitor approximately an arm's length away from the worker?
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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?
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Is the font size, screen contrast and/or image quality in print and on the monitor acceptable?
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If a document holder is used, is the document holder located adjacent to the monitor?
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Actions taken:
- 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
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Comments on Monitor & Source Document:
Phone & Printer
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Is the phone located on the same side as the hand that is used to answer it?
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Handset/Headset:
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Can the phone be answered without extended reaching?
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Does the employee talk on the phone without cradling it on their shoulder?
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Does the employee utilize speaker phone or a headset while participating in conference calls?
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Does the employee have a printer?
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Can the printer be accessed without extended reaching?
- Yes
- No
- It is a community printer is not located at their workstation
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Actions taken:
- 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
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Comments on phone and/or printer:
Work Surface
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Is there sufficient space for all equipment and accessories?
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Are frequently used equipment and supplies within an arm's reach?
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Is the work surface height adjustable?
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- Cube desk that is only adjustable up
- Sit/Stand workstation
- Fully adjustable desk
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Actions taken:
- Reorganized equipment
- Reorganized furniture
- Adjusted work surface height
- Reevaluate the work surface height during the follow up assessment
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Comments on Work Surface:
Workspace
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Is the CPU in a location that does not interfere with positioning of the employee at the workstation?
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Can the employee move about the workspace easily, free from equipment or supplies obstructing movement?
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Is there adequate leg clearance (height, width, depth)?
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Is there sufficient storage and filing room to keep the work area free from clutter?
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Actions taken:
- Repositioned CPU
- Reorganized work space
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Comments on Workspace
Environment
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Is lighting adequate for all tasks?
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Is the monitor screen free of glare from overhead lighting?
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Are monitors free from glare from windows?
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- 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
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Is the workstation climate acceptable?
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Actions taken:
- Reduced overhead lighting
- Changed location of monitor(s)
- Adjusted blinds, curtains, etc.
- Adjusted the work station climate
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Comments on Environment
Evaluator Actions
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Evaluator Actions
- 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.
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Summary of Recommendations
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Recommendations:
- 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:
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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
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Employee:
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Risk Management Representative: