Information

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • Pain/Stiffness?

Chair

  • Seat Height

  • Seat Back

  • Seat Pan Depth

  • Seat Pan Tilt

  • Armrest Position

Keyboard and Mouse

  • Keyboard Height

  • Keyboard-to-User Distance

  • Keyboard Slope

  • Mouse-to-User Distance

  • Mouse Height

Monitor

  • Monitor Height

  • Screen-to-User Distance

  • Monitor Alignment with User

  • Visual Comfort with Screen

Work Environment and Surface

  • Leg Clearance at Workstation

  • Placement of Frequently Used Items

  • General Task Lighting

Work Practices

  • Frequency of Microbreaks

  • Keyboarding Posture

  • Sitting Posture

  • Phoning Posture

  • Alternate Tasks

Evaluation Comments and Recomendations

Required Items to Achieve Safe Workstation Design

  • Adjustable Ergonomic Chair

  • Adjustable Keyboard/Mouse Tray

  • Lumbar Support Cushion

  • Monitor Riser

  • Foot Rest

  • Wristrest Pad

  • Anti-glare Screen

  • Reference Document Holder

  • Telephone Headset

  • Office Ergonomics Training

  • Other

Review and Verification (The evaluator has reviewed neutral body position, safe workstation design, best work practices, and recommendations with the user.)

  • Employee Signature

  • Evaluator Signature

Ergonomic Evaluation Guidelines

Chair

  • Seat Height - Adjust seat so feet are flat on the floor or footrest, knees are bent at right angles, and thighs are horizontal to the floor

  • Seat Back - Adjust seat back so it supports the lumbar curve of the spine.

  • Seat Pan Depth - Adjust the seat pan depth so the seat cushion is between one and four inches from the back of the knees.

  • Seat Pan Tilt - Adjust seat pan tilt so hips and top of thighs are at right angles or greater.

  • Armrest Position - Adjust armrests so they are out of the way during typing, but may provide support during other activities.

Keyboard and Mouse

  • Keyboard Height - Adjust keyboard height so arms and forearms are at right angles or slightly greeter and forearms and hands form straight lines.

  • Keyboard-to-User Distance - provide enough distance to allow user to relax shoulders with elbows hanging close to body.

  • Keyboard Slope - Position keyboard at flat or slightly negative slope.

  • Mouse-to-User Distance - Mouse should be directly next to keyboard.

  • Mouse Height - Adjust mouse so it is as close to and on the same level as keyboard.

Monitor

  • Monitor Height - Adjust monitor height so top of screen is at or slightly lower than eye level.

  • Screen-to-User Distance - viewing distance is approximately arm's distance away (16"-28")

  • Monitor Alignment with User - monitor and keyboard should be placed directly in front of user.

  • Visual comfort of screen - monitor should be placed perpendicular to window or light source to avoid glare.

Work Environment and Surface

  • Leg clearance at workstation - do not allow any contact between thighs and desk and allow room to move legs without contacting desk.

  • Placement of frequently placed items - place with arms reach or as close as possible.

  • General task lighting - ensure lighting is not direct or to bright

Work Practices

  • Frequency of Microbreaks - get out of chair at least once per hour, microbreak every 60 minutes

  • Keyboarding Posture - keep wrists straight, avoid supporting wrists on any surface while typing.

  • Sitting Posture - upright or slightly reclined posture, maintain hollow in lower back.

  • Phoning posture - avoid tilting head/neck to cradle phone. Use hand to hold receiver.

  • Alternate tasks - break up long periods of continuous computer use by performing small tasks or errands.

  • Photograph of Workstation

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.