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Self-Assessment

Employee Self-Assessment Form

Step 1 of 10 - Employee Information

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Name*
First Last
Email*
Phone*
Workstation Address*
Street Address Address Line 2 City State ZIP Code
Work Hours*
District*
Hidden
District Contact Email
Site / Department*
Upload Photos of Workspace
Please include pictures of the front of workstation, back of workstation, side profile of workstation, mouse, and any other equipment that you frequently use.
Drop files here or
Max. file size: 256 MB.
Employee Height*
Employee Weight (Range)
Hidden
Employee Weight

Discomfort Level
The purpose of this checklist is to assist you in identifying awkward postures and positions that your workstation may be causing you as a result of inadequate setup. The goal is to help you prevent repetitive stress injuries related to computer work.
Rate your discomfort level for the following areas
Back of neck
- None
- Mild
- Severe
Shoulders
- None
- Mild
- Severe
Lower Back
- None
- Mild
- Severe
Elbows
- None
- Mild
- Severe
Forearms
- None
- Mild
- Severe
Wrists
- None
- Mild
- Severe
Fingers
- None
- Mild
- Severe
Eyes
- None
- Mild
- Severe
Thighs
- None
- Mild
- Severe
Knees
- None
- Mild
- Severe
Lower legs
- None
- Mild
- Severe
Ankles / feet
- None
- Mild
- Severe

Legs, Knees, Thighs & Back
What to look for: Sitting Posture
How long have you been experiencing discomfort in this area?*
- less than 3 months
- 3 - 6 months
- 6 - 9 months
- 9 - 12 months
- over a year
Do you have enough leg room under the desk when sitting on your chair?*
- Yes
- No
- N/A
While sitting: Do you have between 2 to 4 fingers of space between the back of your knees and the chair seat?*
- Yes
- No
- N/A
Are your knees slightly higher than your hips? Meaning: are your thighs parallel to the floor?*
- Yes
- No
- N/A
Is the back rest meeting your natural spinal curve?*
- Yes
- No
- N/A
Is the back rest higher than your hips area?*
- Yes
- No
- N/A
Possible Solutions/Tips
- Don’t be afraid to try out the adjustments on your chair (back, height, tilt, armrests).
- Adjusting your chair properly is the base of good spinal alignment, improved circulation, reduction of a “hunched” upper back & neck, and reduced accumulation of tension.
- Use the seat tilt adjustment.
- Use the seat pan length adjustment.
- Sit back on your chair, tuck in your abdominal muscles while sitting down.

Ankles & Feet
What to look for: Feet flat on the floor
How long have you been experiencing discomfort in this area?*
- less than 3 months
- 3 - 6 months
- 6 - 9 months
- 9 - 12 months
- over a year
Do your feet provide support to your thighs and lower back?*
- Yes
- No
- N/A
Do your feet have adequate circulation throughout the day?*
- Yes
- No
- N/A
Do you have discomfort in your feet and ankles throughout the day?*
- Yes
- No
- N/A
Possible Solutions/Tips
- Adjust the height of your chair so your feet are flat on the ground
- Feet should be placed directly in front of the user

Neck & Head
What to look for...
How long have you been experiencing discomfort in this area?*
- less than 3 months
- 3 - 6 months
- 6 - 9 months
- 9 - 12 months
- over a year
Have you adjusted the monitor so the top of the screen is at or slightly below eye level?*
- Yes
- No
- N/A
Is the monitor directly in front of you and exactly at arm’s length?*
- Yes
- No
- N/A
If you use a document holder; is it directly between the monitor and the keyboard or adjacent to the monitor?*
- Yes
- No
- N/A
Are you able to put the phone down while looking up information on the computer?*
- Yes
- No
- N/A
Possible Solutions/Tips
- Place documents directly in front of you.
- Avoid cradling the phone in your neck.
- Consider a telephone Headset if you have heavy phone usage and are required to answer the phone and look at the computer screen simultaneously.

Arms, Wrists, Hands & Fingers
What to look for: Typing & Mousing
How long have you been experiencing discomfort in this area?*
- less than 3 months
- 3 - 6 months
- 6 - 9 months
- 9 - 12 months
- over a year
Can you adjust your keyboard and mouse at or slightly lower than elbow height?*
- Yes
- No
- N/A
Are your wrists straight while operating the keyboard and mouse?*
- Yes
- No
- N/A
Are your shoulders relaxed while your work? Meaning: do you find yourself elevating your shoulders to type and mouse?*
- Yes
- No
- N/A
Is the mouse at the same level as and adjacent to the keyboard?*
- Yes
- No
- N/A
Do you know the proper way to type and mouse to minimize risk for injury to the wrists?*
- Yes
- No
- N/A
Possible Solutions/Tips
- Avoid pressing your wrists on any hard surface, including the wrist rests.
- Learn the “neutral” position for typing and mousing and practice a good “neutral” flow of movement.
- If you find yourself pressing; remove the wrist rests and place keyboard at the edge of tray; if your elbows are bent and Is the mouse at the same level as and adjacent

Eyes
What to look for...
How long have you been experiencing discomfort in this area?*
- less than 3 months
- 3 - 6 months
- 6 - 9 months
- 9 - 12 months
- over a year
Is the monitor positioned so as to avoid glare or reflection?*
- Yes
- No
- N/A
Are the fonts and images sharp, clear and easy to read?*
- Yes
- No
- N/A
Is there adequate lighting?*
- Yes
- No
- N/A
Are you able to take short breaks from the screen?*
- Yes
- No
- N/A
Possible Solutions/Tips
- Place monitor perpendicular to windows and use blinds to prevent glare.
- Are the fonts and images sharp, clear and easy to read?
- Try gazing at a distant object or blinking to give your eyes a break.
- Use added task light when reading documents. Is there adequate lighting?

Shoulders
What to look for...
How long have you been experiencing discomfort in this area?*
- less than 3 months
- 3 - 6 months
- 6 - 9 months
- 9 - 12 months
- over a year
Are your keyboard and mouse positioned at elbow height?*
- Yes
- No
- N/A
Is your monitor at an arm’s length?*
- Yes
- No
- N/A
Possible Solutions/Tips
- Place mouse and keyboard at elbow height.
- Monitor distance should be 23-29 inches away from you.
- Line of sight should be one-third of the way down from the top of your screen.

Good Habits, Listen To Your Body
What to look for...
Do you often take short breaks when typing and mousing for long periods of time?*
- Yes
- No
- N/A
Are you able to stand and walk around throughout your day?*
- Yes
- No
- N/A
Do you stop and stretch when feeling tension in neck, shoulders or hands?*
- Yes
- No
- N/A
Do you understand the concept of “working in neutral” posture to prevent injuries?*
- Yes
- No
- N/A
Possible Solutions/Tips
- It is important to listen to your body and recognize the onset of symptoms of discomfort
- Tension that leads to injury accumulates in our body/soft tissue when working in awkward positions.
- Take frequent breaks from lengthy typing and mousing as well as from sitting for long periods of time.
- Alternate your tasks.

Environmental
What to look for...
Is temperature and noise level appropriate?*
- Yes
- No
- N/A
Are there other people sharing your workstation?*
- Yes
- No
- N/A
Is your workstation conducive to concentration and privacy?*
- Yes
- No
- N/A

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