Ergonomic Assessment - duplicate

• Document No.

• Audit Title

General Information:

• Date Evaluation Requested

  Date

• Evaluation Date

  Date

• Employee Name:

• Employee Title:

• Employee Manager / Supervisor:

• Operation

  1-3 Hours a Week

  3-6 Hours a Week

  6-9 Hours a Week

  9-12 Hours a Week

  No Overtime

• Work Area

  Administration

  Fleet

  Operations

  Communications

• Reason for Ergonomic Evaluation

  Select Initial Placement General Concern Preventive Annual Evaluation Work Station Evaluation Ergonomic Equipment Request Pain or Discomfort

  • Initial Placement
  • General Concern
  • Preventive
  • Annual Evaluation
  • Work Station Evaluation
  • Ergonomic Equipment Request
  • Pain or Discomfort

• Physical Complaint

  Select Head Headache Neck Chest Abdominal Pelvis Legs Arms Back Wrist None

  • Head
  • Headache
  • Neck
  • Chest
  • Abdominal
  • Pelvis
  • Legs
  • Arms
  • Back
  • Wrist
  • None

• Location of Pain

  Select Upper Right Upper Left Right Left Upper Lower Lower Right Lower Left None

  • Upper Right
  • Upper Left
  • Right
  • Left
  • Upper
  • Lower
  • Lower Right
  • Lower Left
  • None

• Comments:

• Treatment

  Workers Compensation Claim

  PMD Treatment

  None

• Claim Number:

• Treatment Outcome

  Restrictions

  Recommendations

  None

• Comments:

• Evaluator:

  Bobby E. Beall Jr.

  Michael Hill

• Basic Tasks

• Extra-Curricular Activities / Hobbies

Hours Worked Per Week:

• Hours Worked Per Week

  0-8 Hours a Week

  8-16 Hours a Week

  16-24 Hours a Week

  24-32 Hours a Week

  32-40 Hours a Week

• Overtime Hours Per Week

  1-3 Hours a Week

  3-6 Hours a Week

  6-9 Hours a Week

  9-12 Hours a Week

  No Overtime

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

  0-2 Hours a Day

  2-4 Hours a Day

  4-6 Hours a Day

  6-8 Hours a Day

• Phone Usage

  0-30 Minutes a Day

  30-90 Minutes a Day

  90-120 Minutes a Day

  120+ Minutes a Day

General Working Postures:

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

  Yes

  No

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

  Yes

  No

• Is trunk perpendicular to floor?

  Yes

  No

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

  Yes

  No

• Are uppers arms and elbows close to the body?

  Yes

  No

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

  Yes

  No

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

  Yes

  No

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

  Yes

  No

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

  Yes

  No

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

  Yes

  No

• Comments:

Work Station:

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

  Yes

  No

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

  Yes

  No

• Alternates between typing and non typing work?

  Yes

  No

• Awkward body positions kept to a minimum?

  Yes

  No

• Are back twisting movements kept to a minimum?

  Yes

  No

• Are frequently used items within easy reach?

  Yes

  No

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

  Yes

  No

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

  Yes

  No

• Does workstation and equipment have sufficient adjustability?

  Yes

  No

• Computer workstation maintained and serviceable?

  Yes

  No

• Copy or Document holder used?

  Yes

  No

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

  Yes

  DNA

• Comments:

Computer Monitor:

• Monitor directly in front of employee?

  Yes

  No

• Is the viewing distance 16-24 inches?

  Yes

  No

• Top line of screen at eye level?

  Yes

  No

• Screen free of glare/reflection?

  Yes

  No

• Visual comfort okay?

  Yes

  No

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

  Yes

  No

• Dual Monitors Side by side?

  Yes

  DNA

• Comments:

Office Chair:

• Feet rest firmly on the floor?

  Yes

  No

• Upper legs parallel to floor?

  Yes

  No

• Lower back supported?

  Yes

  No

• Seat length appropriate?

  Yes

  No

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

  Yes

  No

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

  Yes

  No

• Backrest provides support for lower back?

  Yes

  No

• Seat width and depth accommodating for user?

  Yes

  No

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

  Yes

  No

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

  Yes

  No

• Comments:

Keyboard / Mouse:

• Forearms parallel to floor?

  Yes

  No

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

  Yes

  No

• Keyboard directly in front of employee?

  Yes

  No

• Keyboard / Mouse gripped and used with mild force?

  Yes

  DNA

• Comments:

Telephone:

• Phone distance at a comfortable reach?

  Yes

  No

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

  Yes

  DNA

• Does phone have speaker or headset capabilities?

  Yes

  DNA

• Comments:

Findings :

• Evaluation Findings:

• Ergonomic Concern Details:

Ergonomic Recommendations:

• Ergonomic Action

• Recommendation:

  Select 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:

  • 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:

• Recommendation:

  Select 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:

  • 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:

• Recommendation:

  Select 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:

  • 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:

• Recommendation:

  Select 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:

  • 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:

• Comments:

• Detail Action Recommendations:

• Employee Signature

  Sign

• Date of Signature

  Date

• Evaluator Signature

  Sign

• Date of Signature

  Date