Free Workplace Ergonomics Review Form Template
Workplace Ergonomics Review Form
Please complete this form thoroughly to ensure a comprehensive evaluation.
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REVIEWER INFORMATION |
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Reviewer Name |
Mikey Goldberg |
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Professional Background |
[Your Professional Background] |
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Contact Information |
[Your Phone Number] |
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Date of Assessment |
[MM/DD/YYYY] |
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EMPLOYEE INFORMATION |
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Employee Name |
Jane Smith |
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Job Title |
Project Manager |
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Department |
Marketing |
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WORKSTATION SETUP |
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Aspect |
Review |
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Chair Type |
Ergonomic office chair |
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Chair Height |
[Employee Chair Measurement] |
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Desk Type |
[Employee Desk Type] |
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Desk Height |
[Employee Desk Height] |
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Monitor Placement |
[Angle and Distance from Monitor] |
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Keyboard and Mouse Position |
[Alignment with Standards] |
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Lighting |
[Workstation Lighting Condition] |
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EMPLOYEE ASSESSMENT |
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Aspect |
Items |
Assessment |
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Posture and Movement |
Sitting/Standing Posture |
Good sitting posture |
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Required Movements |
[Comfort Description] |
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Health and Comfort Concerns |
Existing Health Issue(s) |
[List Health Issue(s) if any] |
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Specific Discomfort Areas |
[Details of Discomfort] |
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RECOMMENDATIONS |
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Recommendation |
Details |
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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].
