Title Page

undefined

  • Name

  • Position

  • Work Unit

  • Conducted on

  • Prepared by

  • Reason for Assessment

  • Details

  • Given ergonomic handbook?

Personal Factors

  • Handed

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

  • Configuration

  • Layout

  • 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

  • Adjustments fully operational

  • Individual finds chair comfortable

  • Two to three fingers between calves and seat pan edge

  • Changes to Seatpan

  • Height

  • Angle

  • Depth

  • Changes to Armrests

  • Height

  • Width

  • Depth

  • Armrests fit individual

  • Armrests do not interfere with workstation

  • Changes to Backrest

  • Lumbar

  • Height

  • Angle

  • Comments

Keyboard and Mouse

  • Work Surface

  • Height

  • Surface Height

  • Tray Height

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

  • Positioned in line with monitor

  • Comments

Monitor

  • Number

  • Use of each monitor (%)

  • Widescreen

  • Height Adjustable

  • Height

  • Depth

  • Angle

  • 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

  • Photos (as required)

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.