Information
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Document No.
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Audit Title
General Information:
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Date Evaluation Requested
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Evaluation Date
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Employee Name:
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Employee Title:
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Employee Manager / Supervisor:
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Operation
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Work Area
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Reason for Ergonomic Evaluation
- Initial Placement
- General Concern
- Preventive
- Annual Evaluation
- Work Station Evaluation
- Ergonomic Equipment Request
- Pain or Discomfort
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Physical Complaint
- Head
- Headache
- Neck
- Chest
- Abdominal
- Pelvis
- Legs
- Arms
- Back
- Wrist
- None
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Location of Pain
- Upper Right
- Upper Left
- Right
- Left
- Upper
- Lower
- Lower Right
- Lower Left
- None
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Comments:
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Treatment
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Claim Number:
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Treatment Outcome
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Comments:
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Evaluator: Margie Groat
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Basic Tasks
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Extra-Curricular Activities / Hobbies
Hours Worked Per Week:
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Hours Worked Per Week
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Overtime Hours Per Week
Desk Devices:
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Desk Top Monitor
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Dual Monitors
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Desk Top Computer
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Lap Top Computer
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Docking Station for Lap Top Computer
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Ergonomic Keyboard
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Key Board Wrist Support
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Mouse
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Mouse Wrist Support
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Desk Top Scanner
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Document Holder
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Phone
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Phone Head Set
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Receiver Horn
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Electronic Stapler
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Lumbar Back Support
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Footrest
Computer / Phone Usage:
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Computer Usage
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Phone Usage
General Working Postures:
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Is Head and Neck upright, or in-line with torso?
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Is head, neck,and trunk facing forward (not twisted)?
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Is trunk perpendicular to floor?
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Are shoulders and upper arms in-line with torso (perpendicular to the floor when relaxed)
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Are uppers arms and elbows close to the body?
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Are forearms, wrists, and hands straight and in-line (forearm 90 degrees to upper arm)?
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Are wrists and hands straight and not at an angle?
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Are thighs parallel to the floor and the lower legs perpendicular to the floor?
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Are feet rested flat on the floor or on a stable surface?
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Do the thighs have sufficient clearance space between the top of the thighs and the work platform?
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Comments:
Work Station:
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Are mini-breaks/pauses (2-3 mins for every 30 mins of computer work) taken?
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Takes short eye breaks (30 seconds for every 30mins working)?
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Alternates between typing and non typing work?
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Awkward body positions kept to a minimum?
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Are back twisting movements kept to a minimum?
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Are frequently used items within easy reach?
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Are all cables and/or cords kept out of the way?
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Is there adequate room for the accessories / documents used?
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Does workstation and equipment have sufficient adjustability?
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Computer workstation maintained and serviceable?
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Copy or Document holder used?
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Input device(s) height at or just below the elbows?
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Comments:
Computer Monitor:
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Monitor directly in front of employee?
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Is the viewing distance within arms distance?<br>
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Top line of screen at eye level?
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Screen free of glare/reflection?
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Visual comfort okay?
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User with bifocals/trifocals able to read without bending head or neck backwards?
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Dual Monitors Side by side?
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Comments:
Office Chair:
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Feet rest firmly on the floor?
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Upper legs parallel to floor?
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Lower back supported?
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Seat length appropriate?
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Chair adjusted so arms are relaxed and close to body?
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Chair has a minimum Five (5) Point base?
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Backrest provides support for lower back?
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Seat width and depth accommodating for user?
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Does the back of the seat not press against the back of the knees and lower legs?
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Is the seat cushioning rounded with a "waterfall" front?
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Comments:
Keyboard / Mouse:
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Forearms parallel to floor?
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Wrists straight and level (not bent left or right)?
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Keyboard directly in front of employee?
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Keyboard / Mouse gripped and used with mild force?
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Comments:
Telephone:
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Phone distance at a comfortable reach?
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Phone used while on computer with hands free or ergonomic device?
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Does phone have speaker or headset capabilities?
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Comments:
Findings :
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Evaluation Findings:
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Ergonomic Concern Details:
Ergonomic Recommendations:
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Ergonomic Action
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Recommendation:
- Anti-Glare Screen
- Back Support
- Footrest
- Headset
- Chair Adjustment
- Chair Installation
- Monitor Adjustment
- Task Lamp
- Corrective Lenses
- Vision Testing
- Document / Copy Holder
- Wrist Rest
- Other:
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Recommendation:
- Anti-Glare Screen
- Back Support
- Footrest
- Headset
- Chair Adjustment
- Chair Installation
- Monitor Adjustment
- Task Lamp
- Corrective Lenses
- Vision Testing
- Document / Copy Holder
- Wrist Rest
- Other:
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Recommendation:
- Anti-Glare Screen
- Back Support
- Footrest
- Headset
- Chair Adjustment
- Chair Installation
- Monitor Adjustment
- Task Lamp
- Corrective Lenses
- Vision Testing
- Document / Copy Holder
- Wrist Rest
- Other:
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Recommendation:
- Anti-Glare Screen
- Back Support
- Footrest
- Headset
- Chair Adjustment
- Chair Installation
- Monitor Adjustment
- Task Lamp
- Corrective Lenses
- Vision Testing
- Document / Copy Holder
- Wrist Rest
- Other:
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Comments:
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Detail Action Recommendations:
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Employee Signature
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Date of Signature
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Evaluator Signature
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Date of Signature