LC DSE Assessment

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

User Details:

• Collar Number, Name, Role, Location

Usage:

• Department?

• Workstation?

• Hours Worked?

• Disability / Medical Issues?

  Yes

  No

  List

• Restricted?

  Yes - FMA

  Yes

  No

• Typing Style?

• Handedness:

  Left

  Right

• Work Use (Hours per Day)?

• Home Use (Hours per Day)?

• Work - Hours per Day?

  1 - 2

  3 - 5

  6 - 8

• Work - Days per Week

  1 - 3

  4 - 5

  6 - 7

• Duration (without getting out of chair)?

  0 - 60 mins

  61 - 120 mins

  121+

User Risks:

• Is the user free from Restricted or Recuperative Duties by the FMA?

  Yes

  No

  N/A

• Is the user free from existing musculoskeletal injuries?

  Yes

  No

  N/A

• Disability or Medical Conditions:

• Has the user undertaken any DSE training? Aware of the 12 Point Plan?

  Yes

  No

  N/A

Chair Details: (Are the following suitable for the user:)

• General Acceptable Repair?

  Yes

  No

  N/A

• Backrest?

  Yes

  No

  N/A

• Seat Height?

  Yes

  No

  N/A

• Seat Pan Size? (too large / small)

  Yes

  No

  N/A

• Armrest?

  Yes

  No

  N/A

• Footrest if required?

  Yes

  No

  N/A

Keyboard / Mouse / Telephone:

• Is the keyboard positioned straight onto the screen on a flat side of the desk?

  Yes

  No

  N/A

• Is the mouse positioned close to the keyboard?

  Yes

  No

  N/A

• Mouse Use?

• Is the phone positioned on opposite of the lead hand?

  Yes

  No

  N/A

• Is the phone positioned appropriately?

  Yes

  No

  N/A

• Is a headset used?

  Yes

  No

  Required

  Not Required

Screen:

• Is the screen positioned on a flat side of the desk?

  Yes

  No

  N/A

• Is the screen at an acceptable distance from the user?

  Yes

  No

  N/A

• Is the screen height correct?

  Yes

  No

  N/A

• Is the screen clear and free from flicker?

  Yes

  No

  N/A

• Is the screen free from Glare?

  Yes

  No

  N/A

• Are blinds available and suitable?

  Yes

  No

  N/A

General Hazards:

• Is the desk suitable and free from damage?

  Yes

  No

  N/A

• Document Position?

• Equipment Position?

• Work Area Details?

• Work Routine?

• Has the user had an eye test?

  In last 12 months

  In last 24 months

  Over 24 months

  Unknown

• Is the thermal comfort acceptable?

  Yes

  No

  N/A

• Are the any faults displayed?

  Yes

  No

  N/A

• Software used? Any issues?

• Health related issues?

• Any other issues or concerns?

Notes and Comments:

• Details off findings and recommendation:

• Any other information:

Sign Off:

• Assessed User:

  Sign

• Assessor:

  Sign