Workplace Ergonomics Assessment Form
Employee Name
Date
Department
Assessor Name
Workstation Description
Chair
Is the chair adjustable?
Yes
No
Does the chair provide adequate support?
Yes
No
Desk
Is the desk height appropriate?
Yes
No
Is there adequate space under and on the desk?
Yes
No
Monitor
Is the monitor positioned at eye level?
Yes
No
Is the monitor at a comfortable viewing distance?
Yes
No
Accessories
Is the keyboard/mouse positioned correctly?
Yes
No
Lighting
Is the lighting adequate?
Yes
No
Additional Comments / Observations