OSHA Ergonomic Assessment Checklist

• Client / Site

• Date and Time of Assessment

  Date

• Activity Assessed

• Organization

• Point of contact

• Personnel observed

• Assessed by

• Location
  Address

Risk Factors

• Any of the workers previously diagnosed with any of the following CTD's: Carpal tunnel, Tendonitis, Tenosynovitis, De Quervain's disease, Trigger Finger, White finger, Hand Arm Segmental Vibration Syndrome, Muscle strains, or Back ailments?

  No

  Yes

  N/A

• Any worker complaints concerning ergonomic issues?

  No

  Yes

  N/A

• Do employees perform high repetition tasks? (100 reps/hour to 2000 per/day)

  No

  Yes

  N/A

• Do the employee's routine tasks require repeated heavy lifting? (>20 lbs) or occasional heavy lifting (>50 lbs)

  No

  Yes

  N/A

• Are employees using awkwardly designed tools, which cause the worker to operate the tool outside of a neutral position for an extended period of time? (> 1 hour)

  No

  Yes

  N/A

• Do employees perform tasks with an awkward head or neck position for an extended period of time? (1 to 3 hours)

  No

  Yes

  N/A

• Do employees perform tasks that require awkward back angles to be held for extended periods of time (2 to 3 hours)? [i.e…hunching, bending, or squatting]

  No

  Yes

  N/A

• Do employees perform tasks with an awkward elbow angle for an extended period of time (1 to 3 hours) or with extreme force application?

  No

  Yes

  N/A

• Do employees perform tasks with an awkward elbow abduction angle for an extended period of time (1 to 3 hours) or with extreme force application?

  No

  Yes

  N/A

• Do employees perform tasks with an awkward wrist flexion angle for an extended period of time (1 to 3 hours) or with extreme force application?

  No

  Yes

  N/A

• Do employees perform tasks with an awkward wrist extension angle for an extended period of time (1 to 3 hours) or with extreme force application?

  No

  Yes

  N/A

• Do employees perform tasks with an awkward back/hip flexion angle for an extended period of time (1 to 3 hours) or with extreme force application?

  No

  Yes

  N/A

• Do employees perform tasks with an extreme reaching distance for an extended period of time (1 to 3 hours) or with extreme force application?

  No

  Yes

  N/A

• Do employees perform tasks with an odd workstation height (either standing or sitting) for an extended period of time (1-3 hours) or with extreme force application?

  No

  Yes

  N/A

• Are high impact tools used routinely? [i.e., riveters, bucking bars, or impact wrenches]

  No

  Yes

  N/A

• Are high vibration producing tools used routinely? [i.e., die grinders, sanders, weed eaters]

  No

  Yes

  N/A

• Do employees perform tasks at an extreme height (high or low) for an extended period of time (1 to 3 hours) or with extreme force application?

  No

  Yes

  N/A

• Are there any other areas of concern either from your observations or employee complaints?

  No

  Yes

  N/A

Completion

• Overall Assessment (Risk Level)

  Low

  Medium

  High

• Recommendation

• Name and Signature of the Assessor

  Sign

• Name and Signature of the Reviewer

  Sign