Collar Number, Name, Role, Location
Disability / Medical Issues?
Work Use (Hours per Day)?
Home Use (Hours per Day)?
Work - Hours per Day?
Work - Days per Week
Duration (without getting out of chair)?
Is the user free from Restricted or Recuperative Duties by the FMA?
Is the user free from existing musculoskeletal injuries?
Disability or Medical Conditions:
Has the user undertaken any DSE training? Aware of the 12 Point Plan?
General Acceptable Repair?
Seat Pan Size? (too large / small)
Footrest if required?
Is the keyboard positioned straight onto the screen on a flat side of the desk?
Is the mouse positioned close to the keyboard?
Is the phone positioned on opposite of the lead hand?
Is the phone positioned appropriately?
Is a headset used?
Is the screen positioned on a flat side of the desk?
Is the screen at an acceptable distance from the user?
Is the screen height correct?
Is the screen clear and free from flicker?
Is the screen free from Glare?
Are blinds available and suitable?
Is the desk suitable and free from damage?
Work Area Details?
Has the user had an eye test?
Is the thermal comfort acceptable?
Are the any faults displayed?
Software used? Any issues?
Health related issues?
Any other issues or concerns?
Details off findings and recommendation:
Any other information: