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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.

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DSE Self Assessment Form Template

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

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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.

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This template is used to evaluate the ergonomics of the work space and to perform an inspection of the areas where display screens are used.

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