Ergonomic Assessment

• Document Number

• Report Title

• Employee Name/Department/Facility

• Date of Assessment

  Date

• Report Author

• Location of Assessment
  Address

• Participating Personnel

Case Information

• Employee name:

• Workstation Location:

• Assessment Details

Chair

• Does the chair meet the requirements of an ergonomic chair?

  Yes

  No

  N/A

• Height of the seat pan properly adjusted?

  Yes

  No

  N/A

• Back angle properly adjusted?

  Yes

  No

  N/A

• Lumbar support feature properly adjusted?

  Yes

  No

  N/A

• Seat pan adjusted properly for adequate lumbar pressure?

  Yes

  No

  N/A

• Armrests adjusted properly?

  Yes

  No

  N/A

Employee Positioning, Computer Components, Workstation Configuration

• Work surface height?

• Can the employee position himself/herself into the workstation properly and without interferences?

  Yes

  No

  N/A

• Customer writing surface installed?

  Absent or not causing extended reach issues.

  Causing extended reach issues.

• Distance between employee and customer; measured from the employee's chest to counter edge is less than or equal to 45 inches?

  Yes

  No

  N/A

• Monitor and other peripheral computer components positioned appropriately?

  Yes

  No

  N/A

• Printer present and positioned properly?

  Yes

  No

  N/A

• Adjustable foot rest present?

  Yes

  No

  N/A

• Document holder present?

  Yes

  No

  N/A

• Computer monitor arm present and properly adjusted?

  Yes

  No

  N/A

Keyboard Tray and Mouse Platform

• Adjustable keyboard tray and mouse platform present?

  Yes

  No

  N/A

• Mounted correctly?

  Yes

  No

  N/A

• Keyboard tray and mouse platform adjusted properly?

  Yes

  No

  N/A

• Corner bracket installed?

  Yes

  No

  N/A

Instruction/Training

• Was ergonomic instruction/training provided to the employee during the assessment?

  Yes

  No

  N/A

• Employee's Signature Acknowledging Instruction/Training:

  Sign

• Assessor's Signature:

  Sign