Employee Name:

Department:

Role:

Years of Service:

Physical Environment Assessment

Lighting:

Brightness Level (Lux):

Adequacy for Tasks: 

• Yes

• No

Temperature:

Average Temperature (°F):

Comfort Level:

• Satisfactory

• Unsatisfactory

Noise:

Average Noise Level (dB):

Disruption Level:

• High

• Medium

• Low

Workstation Ergonomics

Chair Comfort: 

• Excellent

• Good

• Fair

• Poor

Desk Height: 

• Appropriate

• Too High

• Too Low

Monitor Position: 

• Comfortable

• Uncomfortable

Keyboard and Mouse Usage:

• Comfortable

• Uncomfortable

Chemical Usage:

Types of Chemicals Used: 

Frequency of Use:

• Daily

• Weekly

• Monthly

Safety Equipment Availability:

• Yes

• No

Biological Hazards

Exposure to Biological Materials: 

• Yes

• No

Safety Measures in Place: 

• Yes

• No

Machinery Operation

Types of Machinery Used: 

Frequency of Use: 

• Daily

• Weekly

• Monthly

Safety Training Received:

• Yes

• No

• Partial

Maintenance and Safety

Last Maintenance Date:

Reported Issues:

Resolution Status:

• Resolved

• Pending

Safety Training

Last Safety Training Date:

Training Topics Covered:

Emergency Procedures

Familiarity with Emergency Exits:

• Yes

• No

Participation in Drills:

• Yes

• No

Please provide any additional feedback or suggestions regarding workplace safety and hazard mitigation: