Answered step-by-step☒ Pain ☐ Injury ☐ RTW/Accommodation ☐ Interest/education...
☒ Pain ☐ Injury ☐ RTW/Accommodation ☐ Interest/education ☐ Other | Eye Dominance: ☐ Left ☐ Right Hand Dominance: ☐ Left ☐ Right Height: | |||
| Equipment Inventory: | ||||
☐ Chair:
| ☐ Mouse:
| ☐ Document Holder:
| ☐ Other:
| |
☐ Keyboard:
| ☐ Monitor(s):
| ☐ Footrest:
| ☐ Other:
| |
| Preferred Posture | Proper Adjustment/ Position/Posture | Action Required (for any No responses) | ||
| Yes | No | ||
| Thigh parallel to floor | ☐ | ☐ | ☐ raise/lower chair ☐ add/remove footrest ☐ | |
| Feet on floor | ☐ | ☐ | ☐ raise/lower chair ☐ add/remove footrest ☐ limitshoe heel height ☐ | |
| Adequate back support | ☐ | ☐ | ☐ contact supervisor to review ☐ | |
| Shoulders relaxed and level | ☐ | ☐ | ☐adjust/eliminate armrest ☐raise/lower chair ☐raise/lower workstationheight ☐raise/lower keyboard height ☐ | |
| Elbows at 90° | ☐ | ☐ | ☐adjust/eliminate armrest ☐raise/lower chair ☐raise/lower workstation height ☐raise/lower keyboard height ☐ | |
| 2-3 finger breadth between back of knee and front edge of seat | ☐ | ☐ | ☐adjust seat depth ☐ | |
| Seat pan padded | ☐ | ☐ | ☐contactsupervisor to review chair ☐ | |
| Does worker know how to operate chair | ☐ | ☐ | ☐ Review controls and/or instruction manual ☐ | |
| Yes | No | |
| Seated elbow height equal to desk height | ☐ | ☐ | ☐raise/lower chair ☐raise/lower workstation ☐ |
| Adequate space | ☐ | ☐ | ☐organize desktop surface ☐remove clutter under desk ☐ arrange cabinet/pedestal to minimize body twisting ☐ |
Minimal reaching above shoulder | ☐ | ☐ | ☐Stand to reach overhead items ☐Place frequently used items on desk ☐ |
Minimal reaching below shoulder | ☐ | ☐ | ☐ arrange cabinet/pedestal for easy reach ☐ remove clutter from under desk ☐ |
| Yes | No | |
| Relaxed arm position during keyboarding | ☐ | ☐ | ☐ raise/lower keyboard height ☐raise/lower chair height ☐ |
| Wrists in neutral flexion/ extension | ☐ | ☐ | ☐recheck chair height ☐recheck keyboard height and tilt ☐ |
| Neutral wrist deviation | ☐ | ☐ | ☐ review typing skills ☐attain split keyboard ☐ |
| Relaxed fingers | ☐ | ☐ | ☐ Relaxation exercises, stretches ☐ |
| Longitudinal finger arch maintained | ☐ | ☐ | ☐learn proper keyboarding technique ☐ keep fingernails short ☐ |
| Upright upper torso | ☐ | ☐ | ☐adjust keyboard height ☐move closer to keyboard ☐adjust chair height ☐ adjust posture ☐ |
| Light touch torkeyboard input | ☐ | ☐ | ☐relaxation exercises ☐ review keyboard functioning ☐ |
| Yes | No | |
| Easy reach | ☐ | ☐ | ☐ move closer to work surface ☐ orient mouse closer to keyboard ☐ adjust mouse sensitivity ☐ use sensor pad on split keyboard ☐ |
| Wrist in neutral flexion/ extension | ☐ | ☐ | ☐ adjustmouse height ☐ convert mouse from dominant to non-dominant side ☐ obtain ergonomic mouse ☐ |
| Yes | No | |
| Head neutral posture | ☐ | ☐ | ☐ raise/lower monitor ☐ |
| Eyes looking forward | ☐ | ☐ | ☐ orient screen in front ☐ orient document in front/beside monitor ☐ positioned for dominant eye ☐ |
| Monitor is arm's length from user | ☐ | ☐ | ☐ adjust distance (forward/back) ☐ |
Upper torso relaxed against chair back
| ☐ | ☐ | ☐ move monitor closer ☐ adjust posture ☐ |
| Document and monitor same distance and height from eyes | ☐ | ☐ | ☐ adjust monitor and/or document position ☐ |
| Glare minimized | ☐ | ☐ | ☐ tilt monitor slightly down ☐ adjust monitor brightness ☐ close blinds ☐ contact Facilities for lighting adjustment ☐ use anti-glare screen ☐ use anti-glare/blue-light reduction glasses ☐ |
| Yes | No | |
| Neck/head centered | ☐ | ☐ | ☐ recommend headset ☐ |
| Easy reach | ☐ | ☐ | ☐ orient phone closer ☐ |
| Yes | No | |
| Visual rest every 20 minutes | ☐ | ☐ | ☐ 20-20-20 rule ☐ |
| Regular stretch breaks | ☐ | ☐ | ☐Stretching guide ☐ |
| Alternate task schedule | ☐ | ☐ | ☐ Job rotation, task variety ☐ |
please fill this out and provide recommendations and comments. pretend you are assessing a person in an office.
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