Workplace Ergonomics Review Form

Workplace Ergonomics Review Form

Please complete this form thoroughly to ensure a comprehensive evaluation.

REVIEWER INFORMATION

Reviewer Name

Mikey Goldberg

Professional Background

[Your Professional Background]

Contact Information

[Your Phone Number]

Date of Assessment

[MM/DD/YYYY]

EMPLOYEE INFORMATION

Employee Name

Jane Smith

Job Title

Project Manager

Department

Marketing

WORKSTATION SETUP

Aspect

Review

Chair Type

Ergonomic office chair

Chair Height

[Employee Chair Measurement]

Desk Type

[Employee Desk Type]

Desk Height

[Employee Desk Height]

Monitor Placement

[Angle and Distance from Monitor]

Keyboard and Mouse Position

[Alignment with Standards]

Lighting 

[Workstation Lighting Condition]

EMPLOYEE ASSESSMENT

Aspect

Items

Assessment

Posture and Movement

Sitting/Standing Posture

Good sitting posture

Required Movements

[Comfort Description]

Health and Comfort Concerns

Existing Health Issue(s)

[List Health Issue(s) if any]

Specific Discomfort Areas

[Details of Discomfort]

RECOMMENDATIONS

Recommendation

Details

Workstation Adjustments

Adjust chair height, add lumbar support

Thank you for completing this form. For further assistance or clarification, contact the [Designated Personnel/Department] at [Designated Personnel/Department Phone] or email at [Designated Personnel/Department Email].

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