Title Page

  • Name of Organisation for whom the assessee works.

  • Location of premises where assessment relates
  • Date of Assessment

  • Assessment carried out by

1. Personal Details

  • Please provide your personal details below

  • 1.1 Your Name

  • 1.2 What is your Role?

  • 1.3 Which Department do you work in?

  • 1.4 Who do you report to?

2. About the location of your Workstation

  • You can support ANY or ALL of your answers by clicking

    image_2023-08-15_122827695.png
  • Please take a Photograph to show what your Workstation looks like!

  • 2.1 Where is your Workstation located? E.G., Room X, or Office 1, or in the Packing Room etc. etc.

  • 2.2 Is the lighting in the workspace suitable and sufficient?

  • 2.3 Is there a functional blind to reduce/increase light from the window?

  • 2.4 Is the floor free from boxes, wiring and other obstacles which may cause someone to trip?

  • 2.5 Is the storage of paper and other stationery away from sources of fire?

  • 2.6 Are the wiring and electrical sockets in good working order?

  • 2.7 Is there enough room to change position and vary movement?

  • 2.8 Is the workplace free from distracting equipment noise?

  • 2.9 Is the temperature comfortable to work in throughout the seasons?

  • 2.10 Is the area free from draughts?

3. About the workstation

Workstation

  • 3.1 What type of workstation are you proposing to use? E.G., Office Desk and Chair with 5 Star Base or Rise and Fall Desk or Workbench and Stool etc. etc.

  • 3.2 Is the work surface large enough for all the necessary equipment and documents etc. etc?

  • 3.3 Are all surfaces free from sharp edges which could cause cuts?

  • 3.4 Is the work surface stable?

  • 3.5 Are work surfaces free from glare and reflection?

  • 3.6 Can you comfortably reach all the equipment and papers you need to use?

  • 3.7 Is there sufficient space for thighs and knees?

  • 3.8 Is there space to stretch your legs?

  • 3.9 Is there enough support for hands and wrists?

  • 3.10 What type of Computer are you using on the workstation?

  • 3.11 Is the software suitable for the task?

  • 3.12 Do you have sufficient training and knowledge in the use of the software?

Seating Arrangements

  • 3.13 What type of seating arrangement is in place?

  • 3.14 Is the chair/seat stable? I.E., comfortable, adjustable and on castors or slides?

  • 3.15 Does the chair/seat swivel to give access to other areas of the workstation?

  • 3.16 If the chair/seat is fitted with armrests, can it be manoeuvred close enough to the work surface?

  • 3.17 Are the mechanisms for adjustments easy to operate from a sitting position?

  • 3.18 Is the chair’s height adjustable?

  • 3.19 Does the seat pad provide adequate support for thighs and buttocks?

  • 3.20 Does the chair provide support for the lower back?

  • 3.21 Does the backrest adjust in height and tilt?

  • 3.22 Are forearms horizontal and your eyes just above the top of the screen?

  • 3.23 Are feet flat on the floor, without too much pressure from the seat on the backs of the legs?

  • 3.24 If feet do not touch the ground, do you have a footrest you can use?

  • 3.25 Have you adjusted your chair so as to be comfortable for the work you are doing?

  • 3.26 Do you have room to change your position and vary movement?

Display Screen(s)

  • 3.27 What is the Screen Configuration?

  • Please describe "Other" Screen Type

  • 3.28 Is the screen free from glare and reflections from lights, windows or other images?

  • 3.29 Are you free from strong sources of light in your line of sight?

  • 3.30 Can the screen swivel?

  • 3.31 Can the screen tilt?

  • 3.32 Is the brightness adjustable?

  • 3.33 Is the contrast adjustable?

  • 3.34 Is the image stable, i.e. free of flicker and jitter?

  • 3.35 Are the characters clear and readable?

  • 3.36 Is the text size comfortable to read?

Keyboard and Mouse

  • 3.37 What type of Keyboard are you using on the workstation?

  • Please describe other type of keyboard

  • 3.38 Is the keyboard in good working order?

  • 3.39 Does the keyboard tilt?

  • 3.40 Is the keyboard detachable/movable?

  • 3.41Are the characters on the keys easily readable?

  • 3.42 Does the keyboard have a numeric pad?

  • 3.43 Is it possible to find a comfortable keying position?

  • 3.44 Do you use good technique I.E., YOU DO NOT hit the keys too hard or flex your wrist?

  • 3.45 What type of Mouse/Pointer are you using on the workstation?

  • Please describe other type of Mouse/Pointer

  • 3.46 Has a Mouse/Pointer pad been provided for use with the Mouse/Pointer?

  • 3.47 Is it suitable for the work you have to do?

  • 3.48 Is the Mouse/Pointer positioned close to the user?

  • 3.49 Is there support for the device user’s wrist and forearm?

  • 3.50 Does the device work smoothly at a speed that suits the user?

  • 3.51 Can you easily adjust software settings for speed and accuracy of Mouse/Pointer?

4. Other considerations

  • 4.1 Do you take regular breaks away from looking at a Display Screen?

  • 4.2 Do you suffer from aches or pains during normal work on any of the equipment?

  • 4.3 Do you suffer from eye strain?

  • 4.4 Have you had an eye and eye sight test within the last two years?

  • 4.5 Do you wear glasses as a result of an eye and eye sight test’s recommendations?

5. Declaration

  • Please sign this declaration to say that to the best of your knowledge all the information you have provided is a true reflection of your Workstation arrangements and environment

  • This is my signature

  • If your device does not allow you to add your signature please sign another document, take a photograph of it and upload the photograph in the next question

  • This is a Photograph of my signature

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.