Office Ergonomic Assessment Form
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1
2Office Ergonomic Assessment
Worker Name:
Dominant
Height:
Type of corrective lenses:
Hand:
Ft.
In.
Employer:
Date:
Assessor:
Percentage of time by function
(total of 8 options = 100%)
Diagram of workstation layout
_____ % Data entry/retrieval
_____ % Writing
_____ % Word processing/editing
_____ % Filing
_____ % Using mouse
_____ % Telephone
_____ % 10-key/adding machine
_____ % Other
Hours/day at this workstation:
Floor surface:
Action Item
Item
Description/Comments/Recommendations
Priority*
(check if YES)
CHAIR
MONITOR
KEYBOARD
MOUSE
TELEPHONE
WORK AREA
DESK/
WRITING
SURFACE
OTHER
S895
12/07
* Priority Levels: High (immediately), Medium (within 30 days), Low (for consideration)
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Parent category: Business