Ergonomics Evaluation

• Information collected was used to determine potential risk factors for excess fatigue and the potential for cumulative trauma injuries. The employee’s tasks were evaluated for awkward posture, repetition, environmental considerations and excessive force while working at their computer terminal.

• Employee

• Client

• Title and Contact Information

• Conducted on

  Date

• Prepared by

• Location
  Address

• Report Provided To:

• Photo of workstation

  Media

• Information collected was used to determine potential risk factors for excess fatigue and the potential for cumulative trauma injuries. The employee's tasks were evaluated for awkward posture, repetition, environmental considerations and excessive force while working at his/her computer terminal.

History/ Symptoms/ Complaints

• Job Details

• History/ Symptoms/ Complaints

  Severe

  Moderate

  Mild

Chair/Posture

• Chair is in good condition (stable base, seat swivels and tilts, easy height adjustment, armrests work properly, etc)

  Yes

  No

  N/A

• Chair fits employee correctly (Adjusted to employee: height, backrest, seat pan depth, adequate width, low back supported by chair, arm rest position)

  Yes

  No

  N/A

• Employee maintains proper alignment of extremities, back and head centered over shoulder

  Yes

  No

  N/A

Desk

• Frequently used items within reach

  Yes

  No

  N/A

• Room to write

  Yes

  No

  N/A

• Leg/Knee Clearance

  Yes

  No

  N/A

• Foot rest available if needed

  Yes

  No

  N/A

• Desk is optimal height (26"-34" for sitting station/ 33"-45" for standing station)

  Yes

  No

  N/A

Monitor

• Monitor height/angle is correct or adjustable

  Yes

  No

  N/A

• Monitor is directly in front of person/ dual monitors are set up correctly

  Yes

  No

  N/A

• Copy holder used

  Yes

  No

  N/A

Keyboard

• Keyboard and mouse height and angle correct or adjustable

  Yes

  No

  N/A

• Mouse is appropriate for employee and placed at an acceptable distance.

  Yes

  No

  N/A

• Wrist rests for keyboard and mouse

  Yes

  No

  N/A

Other

• Headset for heavy phone use

  Yes

  No

  N/A

• Comfortable lighting (Overhead/task)

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Additional Observations

• Keyboard Tray

• Footrest

• Monitor Stand

• Wrist rests

• Ergonomic keyboard

• Ergonomic mouse

• Headset for phone

• Document Holder

• Chair

• Other

• Describe Other