User Details

  • Occupation

  • Number of Hours of Use per Day

If you use Display Screen Equipment for less than 1 hour per day then complete section 8 only, otherwise complete sections 1 to 8 below.

Section 1 - Display Screens

  • Are the characters clear and readable on the screen

  • Is the text size comfortable to read

  • Is the image stable - i.e free from flicker or jitter

  • Are the screen graphics suitable for the intended use

  • Is the brightness and contrast adjustable

  • Is the screen at a comfortable viewing height - does the screen swivel & tilt

  • Is the screen free from glare and reflections

  • Are adjustable window coverings suitable for providing adequate shade

Section 2 - Keyboard

  • Is the keyboard separate from the monitor or screen.
    (Select N/A if you use a laptop)

  • Can the keyboard be tilted
    (Select N/A if using a laptop)

  • Is it possible to find a comfortable typing position

  • Do you feel you need additional training on Keyboard Techniques

  • Are the keyboard characters clear and readable

Section 3 - Mouse / Trackball

  • Is the device suitable for its intended use

  • Can the device be positioned close to you without stretching

  • Do you require additional support for forearm or wrist during operation

  • Does the device work smoothly and at a speed that suits you

  • Do you require additional training to change mouse speed in the software settings

Section 4 - Software

  • Is the software you use suitable for its intended use

  • Do you require additional general training on the software you use.
    (Do not include specialised software training if is not a mandatory part of your daily use)

Section 5 - Furniture

  • Is your work station suitable to hold all necessary devices and papers etc.

  • Can you comfortably reach all equipment and papers you need

  • Do you require additional equipment such as a document holder

  • Are all surfaces clear and free from glare or reflection

  • Is your chair comfortable to use

  • Is your seat height adjustable

  • Does your seat have adjustable back height and is it tiltable

  • Does your seat have working casters or glides

  • Do you require additional back support

  • Are your forearms horizontal and your eyes roughly the same height as the top of the screen

  • Can you put your feet flat on the floor without too much pressure from the seat on your legs

Section 6 - Environment

  • Do you have enough room to change position and vary movement

  • Is the lighting at your workstation suitable

  • Does the air feel comfortable ( i.e. not too dry)

  • Can the temperature at the workstation be controlled to produce a comfortable environment

  • Are the levels of noise in your area comfortable

  • Are you able to take regular breaks from Display Screen work

Section 7 - Additional Information

  • Do you have regular eyesight checks. (Minimum every 2 years)

  • Do you require glasses specifically for Display Screen Work and no other reason. outside work

  • If you are a disabled person, do you require any equipment or assistance

  • Do you have any health symptoms or discomfort that you contribute to working with your Display Screen Equipment (If YES please give details)

  • Details of Health Symptoms

  • Do you have any medical or other condition which may affect your working with Display Screen Equipment (If YES please give details)

  • Details of Health Conditions

  • Send to Department


  • Device Being Used

  • Employee Signature Ensure that all questions are answered if completing sections 1 to 7

  • Name

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