Title Page
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Conducted on
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Prepared by
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Location
Customer Info
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Customer Name
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Customer Title
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Customer Department
Temperature
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What is the temperature at the workstation?
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What is the humidity?
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Are the air diffuses aligned to create no draughts?
Lighting
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Is there adequate lighting for all tasks?
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What is the illuminance level?
Noise
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What is the decibel level?
Furniture
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What is the general condition of the furniture?
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Condition of the screen
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Condition of the chair
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Condition and position of the monitor arm
Sign Off
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Completed By
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Completed on
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Manager's Signature
