Ergonomic Evaluation

• Document No.

• Audit Title

• Client / Unit

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel Present

Employee Name and Location

• Employee name:

• Location:

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

• Adjustable foot rest present?

  Yes

  No

  N/A

• Back angle properly adjusted?

  Yes

  No

  N/A

• Lumbar support 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, Work Station

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

  Yes

  No

  N/A

• Work surface height?

• Customer writing surface installed?

  Absent or not causing extended reach issues.

  Causing extended reach issues.

• Monitor and other peripheral computer components positioned appropriately?

  Yes

  No

  N/A

• Printer positioned properly?

  Yes

  No

  N/A

• Document holder positioned appropriately?

  Yes

  No

  N/A

• 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

Keyboard Tray and Mouse Platform

• Adjustable keyboard tray and mouse platform present?

  Yes

  No

  N/A

• Mounted correctly?

  Yes

  No

  N/A

• Corner bracket installed?

  Yes

  No

  N/A

• Keyboard tray and mouse platform adjusted properly?

  Yes

  No

  N/A

Training

• Was the employee trained in ergonomics during the course of the evaluation?

  Yes

  No

  N/A

• Employee's Signature Acknowledging Training:

  Sign

• Evaluator's Signature:

  Sign