Ergonomic Evaluation Self-Assessment Form

    This is a required question
    This is a required question
    This is a required question
    This is a required question
    A. Head and neck to be about upright (not bent down/back).
    B. Head, Neck and trunk to face forward (not twisted).
    C. Trunk to be about perpendicular to floor (not leaning forward/backward).
    D. Shoulders and upper arms to be about perpendicular to floor (not stretched forward) and relaxed (not elevated)
    E. Upper arms and elbows to be close to body (not extended outward).
    F. Forearms, wrists, and hands to be straight and parallel to floor (not pointing up/down).
    G. Wrists and hands to be straight (not bent up/down or sideways toward little finger). 
    H. Thighs to be about parallel to floor and lower legs to be about perpendicular to floor.
    I. Feet to rest flat on floor or be supported by a stable footrest.
    J. COMPUTER tasks to be organized in a way that allows employee to vary COMPUTER tasks with other work activities, or to take micro-breaks or recovery pauses while at the
    Please enter one response per row
    1. Backrest provides support for employee’s lower back (lumbar area). 
    2. Seat width and depth accommodate specific employee (seat pan not too big/small). 
    3. Seat front does not press against the back of employee’s knees and lower legs (seat pan not too long).
    4. Seat has cushioning and is rounded/has “waterfall” front (no sharp edge). 
    5. Armrests support both forearms while employee performs COMPUTER tasks and do not interfere with movement. 
    Please enter one response per row
    6. Keyboard / input device platform(s) is stable and large enough to hold keyboard and input device.
    7. Input device (mouse or trackball) is located right next to keyboard so it can operated without reaching. 
    8. Input device is easy to activate and shape/size fits hand of specific employee (not too big/small).
    9. Wrists and hands do not rest on sharp or hard edge.
    Please enter one response per row
    10. Top line of screen is at or below eye level so employee is able to read it without bending head or neck down/back (For employees with bifocals/trifocals, see next item).
    11. Employee with bifocals/trifocals is able to read screen without bending head or neck backwards.
    12. Monitor distance allows employee to read screen without leaning head, neck or trunk foreward/backward.
    13. Monitor position is directly in front of employee so employee does not have to twist head or neck. 
    14. No glare (e.g., from windows, lights) is present on the screen which might cause employee to assume an awkward posture to read screen.
    Please enter one response per row
    15. Thighs have clearance space between chair and COMPUTER table/keyboard platform (thighs are not trapped).
    16. Legs and feet have clearance space under COMPUTER table so employee is able to get close enough to keyboard/input device.
    Please enter one response per row
    17. Document holder, if provided, is stable and large enough to hold documents that are used
    18. Document holder, if provided, is placed at about the same height and distance as the monitor screen so there is little head movement when employee looks from document to screen. 
    19. Wrist rest, if provided is padded and free of sharp and square edges. 
    20. Wrist rest, if provided, allows employee to keep forearms, wrists and hands straight and parallel to ground when using keyboard/input device.
    21. Telephone can be used with head upright (not bent) and shoulders relaxed (not elevated) if employee does COMPUTER tasks at the same time. 
    Please enter one response per row
    22. Workstation and equipment have sufficient adjustability so that the employee is able to be in a safe working posture and to make occasional changes in posture while performing COMPUTER tasks.
    23. COMPUTER workstation, equipment and accessories are maintained in serviceable condition and function properly.
    Please enter one response per row