DSE Self-Assessment Form Template – Free Download

DSE self-assessment form template

This DSE self-assessment form empowers employees to evaluate their own workstation setup, identifying potential ergonomic issues before they cause discomfort. Research published in the Survey of Ophthalmology reveals that many workers suffer from computer vision syndrome—experiencing eye irritation, dryness, and blurred vision—which can lead to headaches and musculoskeletal pain.

This template helps you proactively address these concerns by enabling staff to assess screen positioning, keyboard comfort, and environmental factors like lighting and temperature. For example , if an employee has increasing neck pain after long hours at her computer, completing this assessment might help them identify that the monitor was positioned too low, allowing for immediate adjustments that prevent further discomfort.

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Preview of the template

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Display Screen Equipment (DSE) Self-Assessment

Do you have any health problems that could be made worse by using a computer?

Do you experience any discomfort or pain when using the computer?

How would you rate the overall comfort of your workstation?

Is the screen positioned at a comfortable viewing distance and height?

Is the screen free from glare and reflection?

Is the screen image stable and free from flicker?

Is the text on the screen clear and readable?

Is the keyboard comfortable to use?

Is the mouse comfortable to use?

Is the work surface large enough for all the equipment?

Is the work surface at a comfortable height?

Is the chair comfortable and adjustable?

Is the seat height adjustable?

Is the backrest adjustable?

Is the footrest provided if required?

Is the lighting suitable, without glare or reflection?

Is the temperature comfortable?

Is the ventilation adequate?

Do you take regular breaks from DSE work?

Have you been provided with information and training on safe DSE use?

Have you been offered an eye test in relation to DSE use?

Additional Comments

Frequently asked questions

What should you do if your DSE self-assessment identifies problems?

First, the employee can try making simple adjustments themselves, like repositioning your screen, adjusting chair height, or improving lighting. Document these changes in the assessment form’s comments section. If issues persist or require equipment purchases, share the completed assessment with the manager or health and safety representative who can help implement appropriate solutions.

Why does the DSE self-assessment form include questions about breaks and training?

These questions address crucial behavioral aspects of ergonomic health. Regular breaks prevent muscle fatigue and eye strain, while proper training ensures you know how to adjust your equipment correctly. Both elements are essential for preventing long-term health issues and are required components of comprehensive DSE assessment under health and safety regulations.

How can you reduce glare on your screen identified during self-assessment?

Reposition your screen perpendicular to windows rather than facing or backing them. Consider using blinds or curtains to control natural light. You can also adjust overhead lighting or use task lamps instead of bright ceiling lights. Anti-glare filters can be attached to your screen if environmental adjustments aren’t sufficient.

What makes the DSE self-assessment form different from a workstation assessment?

The self-assessment form is completed by you, the equipment user, based on your personal experience and comfort. A workstation assessment is typically conducted by a trained assessor who objectively evaluates your setup. The self-assessment serves as an excellent first step, highlighting issues that may require further professional evaluation.

This template, developed by Lumiform employees, serves as a starting point for businesses using the Lumiform platform and is intended as a hypothetical example only. It does not replace professional advice. Companies should consult qualified professionals to assess the suitability and legality of using this template in their specific workplace or jurisdiction. Lumiform is not liable for any errors or omissions in this template or for any actions taken based on its content.