Copyright 2017 Berkley Life Sciences, All Rights Reserved. a Berkley Company

Name: / Job Title:
Company: / Department:
Assessment Performed by: / Date of Assessment:
Describe History of Discomfort:
Computer Usage Average Hours/Day:
Chair / Y / N / N/A / Improvement Recommendations
Thighs parallel to floor? / Adjust chair height
Feet flat on floor and properly supported? / Provide foot rest
Does chair provide for lumbar support? / Provide different chair
Provide external lumbar support
Is lumbar support adjusted comfortably in user’s lumbar region? / Adjust lumbar support
Does the backrest lock in an upright, supportive position? / Provide different chair
Is the seat pan depth adjusted to allow 2-3 fingers width between back of user’s knees and front of seat pan? / Adjust seat pan depth
Provide different chair
Armrests adjusted to just below user’s elbows? / Adjust armrests
Armrests prevent user from getting close enough to workstation? / Remove armrests
Provide chair w/o armrests
Additional Chair Comments:
Keyboard/Tray/Mouse / Y / N / N/A / Improvement Recommendations
Is keyboard positioned such that:
User’s upper arm is hanging naturally from shoulder? / Adjust keyboard height and/or angle.
If keyboard cannot be adjusted to accommodate all of these conditions, then provide an adjustable, articulating keyboard tray or alternate keyboard
User’s forearms are parallel to floor?
User’s wrists are straight and hands are in same plane as forearms?
Is keyboard tray large enough for both keyboard and mouse? / Change keyboard tray
Is keyboard tray stable? / Repair or change keyboard tray
Is mouse positioned adjacent to and at the same height as the keyboard so it can be utilized without excessive reaching? / Relocate mouse
Is the mouse of appropriate size and comfortable to user? / Provide different mouse or pointing device
User’s hands or forearms in contact with hard and/or sharp edges? / Provide padding or wrist rest
For laptop users, are external keyboard and mouse provided? / Provide external devices
Additional Keyboard/Tray/Mouse Comments:

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Monitor/Source Documents / Y / N / N/A / Improvement Recommendations
Is monitor located in front of the user? / Reposition monitor
Is monitor approximately arm’s length away from the user? / Reposition monitor
Is monitor height adjusted such that the top of the viewable portion of the screen is at, or slightly below, eye level, promoting a neutral head posture? / Adjust monitor height
Does user wear bi-focals or tri-focals? / Lower monitor height to promote neutral head posture.
For work performed from hard copy, is a document holder provided? / Provide a document holder
Is document holder located adjacent to monitor? / Relocate document holder
If more than one monitor is used, is the primary monitor located directly in front of the user? / Relocate monitor
For laptop users, is an external monitor used? / Provide external monitor
Additional Monitor/Source Document Comments:
Phone / Y / N / N/A / Improvement Recommendations
Is the phone located on the same side of the workspace as the hand used to answer it? / Move phone to opposite side
Can the phone be used without excessive reaching? / Move phone closer to user
Does the user talk on the phone while performing other tasks, particularly keyboard/computer use? / Provide headset or utilize speaker phone
Additional Phone Comments:
Workspace and Environment / Y / N / N/A / Improvement Recommendations
Is workspace set up so that most frequent work is within 45 degrees to each side of user? / Reconfigure workspace
Are excessive reaches to perform work tasks minimized? / Reconfigure workspace
Are frequent, overhead reaches minimized? / Reconfigure workspace
Is lighting adequate for all tasks? / Provide task lighting
Is monitor free from glare from overhead lighting? / Reduce overhead lighting
Is monitor located perpendicular to windows or windows heavily tinted to prevent significant external lighting? / Use blinds
Is workspace temperature acceptable? / Modify temperature
Additional Workspace and Environment Comments:
Summary: Overall Evaluation and Recommendations