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