Page 1
User Information
User Name
Job Title
Department
How long have you been using the workstation?
Workstation Assessment
Is the chair adjustable?
Is the seat height correct?
Is the seat back adjustable?
Is the seat swivel working?
Is the desk at the correct height?
Is there sufficient legroom under the desk?
Is the monitor positioned at the correct height?
Is the monitor positioned at the correct distance?
Is the keyboard positioned correctly?
Is the mouse positioned correctly?
Is the work surface non-reflective?
Is the lighting adequate?
Is the ventilation adequate?
Health & Safety
Do you experience any discomfort or pain when using the workstation?
If yes, please describe the nature and location of the discomfort or pain.
Have you reported any health concerns related to the workstation?
If yes, what action was taken?
Additional Comments
Please provide any additional comments or concerns about the workstation.