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 15 times

Rated 5/5 stars on Capterra

Say goodbye to paper checklists!

Lumiform enables you to conduct digital inspections via app easier than ever before
  • Cut inspection time by 50%
  • Uncover more issues and solve them 4x faster
  • Select from over 5,000 expert-proofed templates

Digitalize this paper form now

Register for free on and conduct inspections via our mobile app

  • Cut inspection time by 50%
  • Uncover more issues and solve them 4x faster
  • Select from over 4000 expert-proofed templates
Rated 5/5 stars on Capterra

DSE Self Assessment Form Template

Personal Information

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?


Are characters readable?
Is the image free of flickering and movement?
Is the screen free from glares and reflections?


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
Share this template:

Similar templates