Information

  • Document No.

  • Audit Title

General Information:

  • Date Evaluation Requested

  • Evaluation Date

  • Employee Name:

  • Employee Title:

  • Employee Manager / Supervisor:

  • Operation

  • Work Area

  • Reason for Ergonomic Evaluation

  • Physical Complaint

  • Location of Pain

  • Comments:

  • Treatment

  • Claim Number:

  • Treatment Outcome

  • Comments:

  • Evaluator: Margie Groat

  • Basic Tasks

  • Extra-Curricular Activities / Hobbies

Hours Worked Per Week:

  • Hours Worked Per Week

  • Overtime Hours Per Week

Desk Devices:

  • Desk Top Monitor

  • Dual Monitors

  • Desk Top Computer

  • Lap Top Computer

  • Docking Station for Lap Top Computer

  • Ergonomic Keyboard

  • Key Board Wrist Support

  • Mouse

  • Mouse Wrist Support

  • Desk Top Scanner

  • Document Holder

  • Phone

  • Phone Head Set

  • Receiver Horn

  • Electronic Stapler

  • Lumbar Back Support

  • Footrest

Computer / Phone Usage:

  • Computer Usage

  • Phone Usage

General Working Postures:

  • Is Head and Neck upright, or in-line with torso?

  • Is head, neck,and trunk facing forward (not twisted)?

  • Is trunk perpendicular to floor?

  • Are shoulders and upper arms in-line with torso (perpendicular to the floor when relaxed)

  • Are uppers arms and elbows close to the body?

  • Are forearms, wrists, and hands straight and in-line (forearm 90 degrees to upper arm)?

  • Are wrists and hands straight and not at an angle?

  • Are thighs parallel to the floor and the lower legs perpendicular to the floor?

  • Are feet rested flat on the floor or on a stable surface?

  • Do the thighs have sufficient clearance space between the top of the thighs and the work platform?

  • Comments:

Work Station:

  • Are mini-breaks/pauses (2-3 mins for every 30 mins of computer work) taken?

  • Takes short eye breaks (30 seconds for every 30mins working)?

  • Alternates between typing and non typing work?

  • Awkward body positions kept to a minimum?

  • Are back twisting movements kept to a minimum?

  • Are frequently used items within easy reach?

  • Are all cables and/or cords kept out of the way?

  • Is there adequate room for the accessories / documents used?

  • Does workstation and equipment have sufficient adjustability?

  • Computer workstation maintained and serviceable?

  • Copy or Document holder used?

  • Input device(s) height at or just below the elbows?

  • Comments:

Computer Monitor:

  • Monitor directly in front of employee?

  • Is the viewing distance within arms distance?<br>

  • Top line of screen at eye level?

  • Screen free of glare/reflection?

  • Visual comfort okay?

  • User with bifocals/trifocals able to read without bending head or neck backwards?

  • Dual Monitors Side by side?

  • Comments:

Office Chair:

  • Feet rest firmly on the floor?

  • Upper legs parallel to floor?

  • Lower back supported?

  • Seat length appropriate?

  • Chair adjusted so arms are relaxed and close to body?

  • Chair has a minimum Five (5) Point base?

  • Backrest provides support for lower back?

  • Seat width and depth accommodating for user?

  • Does the back of the seat not press against the back of the knees and lower legs?

  • Is the seat cushioning rounded with a "waterfall" front?

  • Comments:

Keyboard / Mouse:

  • Forearms parallel to floor?

  • Wrists straight and level (not bent left or right)?

  • Keyboard directly in front of employee?

  • Keyboard / Mouse gripped and used with mild force?

  • Comments:

Telephone:

  • Phone distance at a comfortable reach?

  • Phone used while on computer with hands free or ergonomic device?

  • Does phone have speaker or headset capabilities?

  • Comments:

Findings :

  • Evaluation Findings:

  • Ergonomic Concern Details:

Ergonomic Recommendations:

  • Ergonomic Action

  • Recommendation:

  • Recommendation:

  • Recommendation:

  • Recommendation:

  • Comments:

  • Detail Action Recommendations:

  • Employee Signature

  • Date of Signature

  • Evaluator Signature

  • Date of 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.