close
lumiform
Lumiform Mobile audits & inspections
Get App Get App

DSE Self Assessment Form Template

Workplace health is determined by many factors. Risk assessments and management can help you determine harmful practices and hazards, maintain safety equipment like emergency eyewash stations or prevent accidents from happening in the first place.

But what about the equipment your employees come into contact with on a daily basis? Like their screens, desks, chairs and workplaces? It is absolutely vital to teach a proper handling of such equipment and offer the most optimal workstations possible to ensure worker’s health.

Use our free self assessment template to determine your employees health in relation to Display Screen Equipment (DSE) at the workstation and create action plans to better practices.

Downloaded 18 times
Personal Information
Name
Department
Location of Workstation
Reason for Assessment
Your Daily Routine
Do you have any problems with your hands, wrists, arms, shoulders, neck or back?
Do you suffer from visual fatigue or headaches?
Screen
Are characters readable?
Is the image free of flickering and movement?
Is the screen free from glares and reflections?
Furniture
Is the large surface large enough for work equipment (monitor, keyboard, documents)?
Are you sitting comfortably? (Suppported by chair, eye-level slightly below DSE screen?)
Is the chair stable?
Do adjustment mechanisms work?
Keyboard & Mouse
Is the keyboard tiltable?
Is there enough space to rest hands in front of keyboard?
Are characters and keys easy to read?
Does the mouse fit comfortably in one hand?
Does the mouse move easily and respond appropriately?
Work Environment
Are levels of light, heat and noise comfortable?
Is the workstation area free from hazards?
Further notes and concerns.
Sign Off
Date & Time
Signature
Share this template:
Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
This site is registered on wpml.org as a development site. Switch to a production site key to remove this banner.