Ergonomic Assesssment Form - Download Checklist

Ergonomic Assesssment Form

About the Ergonomic Assesssment Form

Usual signs of ergonomic stress are body aches, tingling or numbness of the hands or fingers, lack of coordination, and pain when making certain moves. This Occupational Safety and Health Administration (OSHA) ergonomic evaluation checklist assesses employees’ operating routine. Use Lumiform to find risk factors that influence the performance of each worker and provide an overall evaluation of the risk level. Also, solutions were confirmed to stop aggravation of symptoms when found.

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Assessment

Risk Factors

Was any of your employees previously diagnosed with any of the following CTD's: Tendonitis, Tenosynovitis, Carpal tunnel, De Quervain's disease, Trigger Finger, White finger, Hand Arm Segmental Vibration Syndrome, Muscle strains, or Back ailments?

Did any worker state any complaint regarding ergonomic matters?

Do employees perform high repetition tasks? (100 repetitions/hour to 2000 per/day)

Do the worker's routine tasks demand doing heavy lifting repeatedly or occasional heavy lifting?

Are workers using awkwardly created tools, which make the worker perform the device in a not-neutral position for an extended period?

Do workers do tasks with an awkward head or neck position for long time? (more than 1 hour)

Do employees do tasks that need awkward back angles to be held for an extended periods?

Do workers do tasks with an awkward elbow angle for a too long time or with excessive force use?

Do workers do tasks with an awkward wrist flexion angle for too long (more than 1 hour) or with excessive force use?

Do workers do tasks with an awkward back/hip flexion angle for too long (more than 1 hour) or with excessive force use?

Do workers perform tasks with an excessive reaching distance for too long (more than 1 hour) or with excessive force use?

Do workers do tasks with an odd workstation height (standing or sitting) for more than one hour or with excessive force use?

Are high impact tools used frequently?

Are producing tools with high vibration used frequently?

Do workers do tasks at an excessive height (high or low) for more than one hour or with extreme force use?

Are there any other concerns either from your own observations or worker complaints?

Completion

Overall rating of the risk level:

Further recommendation:

Full name and signature of the evaluator:

Full name and signature of the reviewer:

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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.