Checklist Ergonomics

Company Letterhead

{{company_name}}

{{company_address}}

Phone: {{phone}}

Email: {{email}}

Website: {{website}}

Ergonomics Checklist - Assessment Date: {{assessment_date}}

Prepared by: {{assessor_name}}

Department/Area Assessed: {{department_name}}

Employee/Workstation Assessed (if applicable): {{employee_name}}

1. Workstation Setup

1.1. Is the chair adjustable (height, backrest, armrests)? (Yes/No/N/A)

1.2. Is the chair providing good lumbar support? (Yes/No/N/A)

1.3. Are feet flat on the floor or supported by a footrest? (Yes/No/N/A)

1.4. Is the monitor at arm's length and the top of the screen at or slightly below eye level? (Yes/No/N/A)

1.5. Is the keyboard positioned so wrists are straight and forearms are parallel to the floor? (Yes/No/N/A)

1.6. Is the mouse close to the keyboard to avoid overreaching? (Yes/No/N/A)

1.7. Is there adequate space under the desk for legs and movement? (Yes/No/N/A)

Comments: {{workstation_comments}}

2. Lighting and Environment

2.1. Is there adequate lighting to prevent glare and eyestrain? (Yes/No/N/A)

2.2. Are there any sources of glare on the monitor screen? (Yes/No/N/A)

2.3. Is the ambient temperature comfortable? (Yes/No/N/A)

2.4. Are noise levels acceptable and not distracting? (Yes/No/N/A)

2.5. Is the workstation free from obstructions and tripping hazards? (Yes/No/N/A)

Comments: {{environment_comments}}

3. Work Habits and Practices

3.1. Does the employee take regular short breaks (e.g., every 30-60 minutes)? (Yes/No/N/A)

3.2. Does the employee adjust their posture periodically? (Yes/No/N/A)

3.3. Is heavy lifting performed using proper techniques and/or mechanical aids? (Yes/No/N/A)

3.4. Is repetitive work minimized or varied where possible? (Yes/No/N/A)

3.5. Has the employee received training on ergonomic principles? (Yes/No/N/A)

Comments: {{work_habits_comments}}

4. Equipment and Tools

4.1. Are tools and equipment in good working order? (Yes/No/N/A)

4.2. Are tools and equipment appropriate for the task and user? (Yes/No/N/A)

4.3. Are anti-fatigue mats used for standing workstations? (Yes/No/N/A)

4.4. Is specialized ergonomic equipment (e.g., ergonomic keyboard, mouse) provided if needed? (Yes/No/N/A)

Comments: {{equipment_comments}}

5. Identified Issues and Recommendations

Summary of Ergonomic Issues Identified: {{issues_summary}}

Recommended Actions: {{recommendations}}

Responsible Person: {{responsible_person}}

Target Completion Date: {{completion_date}}

Action Status: {{action_status}}

6. Follow-up

Date of Follow-up: {{follow_up_date}}

Follow-up Actions Taken: {{follow_up_actions}}

Outcome of Follow-up: {{follow_up_outcome}}

Signature Block

Assessor Name: {{assessor_name}}

Signature: __________________________

Date: {{signature_date}}

Reviewed by (Manager/HOD): {{reviewer_name}}

Signature: __________________________

Date: {{review_date}}