Ergonomic Assessment Form

OSHA Ergonomics Guidance · General Duty Clause · ANSI/HFES 100-2007 | EHS Community Template

Employee Name

Job Title

Department

Assessment Date

Assessed By (Name / Title)

Work Location / Workstation ID

Primary Tasks Performed (list top 3)

Avg. Hours/Day at This Workstation

Assessment Type

SECTION 1 — EMPLOYEE SYMPTOM SURVEY

Employee: mark any body area where you experience discomfort, pain, or fatigue during or after work. Rate severity: 1 = mild, 5 = severe.

Body Region	Discomfort? (Y/N)	Severity (1–5)	Frequency	Description / When does it occur?
Neck / Upper Trapezius
Shoulders (L / R / Both)
Upper Back
Lower Back / Lumbar
Elbows / Forearms (L / R)
Wrists / Hands (L / R)
Hips / Thighs
Knees
Ankles / Feet
Eyes / Vision Fatigue

Has this discomfort been reported to a supervisor or medical? (Y/N)

Any current medical restrictions / accommodations?

SECTION 2 — WORKSTATION / TASK RISK FACTOR CHECKLIST

Assessor: check all that apply, and note how often and for how long each factor occurs. Risk factors are MSD (musculoskeletal disorder) risk indicators per OSHA ergonomics guidance; this checklist is a screening tool and sets no legal limits.

A. Posture

Posture Risk Factor	Present?	Notes / Frequency
1. Head/neck bent forward or twisted for sustained periods
2. Shoulders elevated, arms raised above shoulder height, or reaching behind body
3. Back bent forward (flexion) or twisted
4. Wrists bent (flexion, extension, or deviation) during repetitive tasks
5. Pinching or contact stress (wrist resting on hard/sharp edge)
6. Sustained standing on hard floor without anti-fatigue matting
7. Prolonged sitting without postural breaks

B. Force & Exertion

Force & Exertion Risk Factor	Present?	Notes / Frequency
8. Lifting / lowering loads above the recommended weight limit for the task (NIOSH Revised Lifting Equation), or without a mechanical assist where one is feasible
9. Pushing or pulling with high force (carts, pallet jacks, stuck loads)
10. Gripping or pinching with high force (tight grasp on tools or materials)
11. Carrying heavy or awkward loads frequently or over long distances

C. Repetition & Duration

Repetition & Duration Risk Factor	Present?	Notes / Frequency
12. Repetitive hand/wrist motions for much of the shift (typing, assembly, scanning)
13. Short work cycles with the same motion repeated throughout the shift
14. Same awkward posture held for long periods

D. Workstation & Environment (Office / Sedentary)

Item	OK?	Recommended Adjustment
15. Monitor directly in front, top of screen at or slightly below eye level, at least 20 inches from the eyes (OSHA Computer Workstations eTool)
16. Chair height allows feet flat on floor (or footrest); thighs parallel to floor
17. Lumbar support present and adjusted to maintain natural curve
18. Keyboard at elbow height; forearms roughly parallel to floor
19. Mouse positioned at same level as keyboard; within easy reach
20. No direct glare on screen; monitor perpendicular to windows
21. Document holder present if referencing documents frequently
22. Phone headset available for frequent phone use (no cradling the phone with the neck)

SECTION 3 — OVERALL RISK RATING

Rate the overall ergonomic risk based on the number and severity of risk factors found. High-risk tasks should be prioritized for immediate corrective action.

Overall Risk Level (suggested targets)

☐ Low — Monitor, standard controls ☐ Medium — Correct within 30 days ☐ High — Correct immediately

Summary of Key Findings

SECTION 4 — CORRECTIVE ACTION PLAN

Recommendation / Control	Category (Eng/Admin/PPE)	Responsible Party	Due Date	Completed?

Follow-up Assessment Scheduled Date

Estimated Cost of Controls

Budget / Cost Center

Employee Signature

Assessor / EHS Representative

Supervisor / Manager

Date

This template is provided for educational purposes by EHS Community (ehscommunity.com). Federal OSHA has no ergonomics standard: the Ergonomics Program standard (29 CFR 1910.900) was disapproved by Congress under the Congressional Review Act (Pub. L. 107-5) and removed from the CFR in 2001 (66 FR 20403). OSHA addresses ergonomic hazards under the General Duty Clause (OSH Act Section 5(a)(1)) and its ergonomics guidance. Some jurisdictions set their own rules, for example Cal/OSHA 8 CCR 5110 and, in Canada, provincial MSI rules such as B.C. OHS Regulation ss. 4.46–4.53. References: ANSI/HFES 100-2007 — Human Factors Engineering of Computer Workstations; NIOSH Revised Lifting Equation (Waters et al., 1994).