Office Ergonomic Assessment

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• Name

• Position

• Work Unit

• Conducted on

  Date

• Prepared by

• Reason for Assessment

  Select Proactive or New station set-up Reactive - Response to a complaint

  • Proactive or New station set-up
  • Reactive - Response to a complaint

• Details

• Given ergonomic handbook?

  Yes

  No

Personal Factors

• Handed

  Right

  Left

Job Task Factors

• Hours worked each week

• Overtime

• Details

• Takes regular scheduled breaks (Lunch, Coffee)

• Gets up from desk during breaks

• Will sit for ___ before getting up

• % of shift on computer

• % of shift doing non-computer activities

• % Using keyboard

• % Using mouse

• Phone call frequency

• Has Headset

• Uses Headset

• Comments

Workplace Factors

• Used by

  Single user

  Multi user

• Configuration

  Straight desk

  L shape

  U shape

  Other

• Layout

  Drawing

• Ample space for tasks, equipment and storage

• Ability to move freely without running into items stored under desk

• Tasks arranged efficiently

• Comments

Chair

• Model/Description

• Photo of Chair

  Media

• Adjustments fully operational

  Off

  On

• Individual finds chair comfortable

  Off

  On

• Two to three fingers between calves and seat pan edge

  Off

  On

• Changes to Seatpan

  Off

  On

• Height

  Raised

  Lowered

• Angle

  Increased

  Decreased

• Depth

  Increased

  Decreased

• Changes to Armrests

  Off

  On

• Height

  Raised

  Lowered

• Width

  Increased

  Decreased

• Depth

  Increased

  Decreased

• Armrests fit individual

  Off

  On

• Armrests do not interfere with workstation

  Off

  On

• Changes to Backrest

  Off

  On

• Lumbar

  Increased

  Decreased

• Height

  Raised

  Lowered

• Angle

  Increased

  Decreased

• Comments

Keyboard and Mouse

• Work Surface

  Desktop

  Rollout Surface

  Adjusting Platform

• Height

  Raised

  Lowered

• Surface Height

• Tray Height

• Mouse and Keyboard on same surface, ample space for both

• Positioned in line with monitor

• Comments

Monitor

• Number

  Single

  Dual

  Multiple

• Use of each monitor (%)

• Widescreen

• Height Adjustable

• Height

  Raised

  Lowered

• Depth

  Increased

  Decreased

• Angle

  Increased

  Decreased

• Comments

Lighting, Noise, HVAC

• Comments

Accessories Required

• Footrest

• Headset

• Keyboard Palm Support

• Mouse Palm Support

• Adjustable Keyboard Platform

• Alternate Keyboard

• Alternate Mouse

• Monitor Riser

• Document Holder

• Task Lighting

• Chair

• Details

• Other

• Details

• Additional Comments

• Completed by

  Sign

• Photos (as required)

  Media