Ergonomic Hazard Assessment Form
Please fill in all sections of this form.
General Information
Item | Details |
Date of Assessment: | [Month Day, Year] |
Department: | |
Assessor's Name: | |
Employee's Name: | |
Job Title: | |
Assessment Location: | |
Workstation Evaluation
Item | Description |
Type of Workstation: | Virtual Interface Console |
Desk/Work Surface: | |
Chair: | |
Equipment Use
Equipment Type | Description |
Computer/Laptop: | Wireless Input |
Other Equipment: | |
Task Analysis
Item | Description |
Frequency of Tasks: | Hourly |
Daily Tasks: | |
Physical Environment
Environmental Aspect | Description |
Lighting: | Optimized LED, No Glare |
Noise Level: | |
Temperature: | |
Recommendations for Improvements
Improvement Area | Suggestions |
Workstation Adjustments: | Additional Footrest, Wrist Pads |
Equipment Upgrades: | |
Work Practices Changes: | |
Training Needs: | |
Signatures
Employee's Signature:
[Name]
[Job Title]
[Month Day, Year]
Assessor's Signature:
[Your Name]
[Job Title]
[Month Day, Year]
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