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Placement & Staffing
Training + Consulting
Mobile First Aid
Full Capabilities Brief
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info@parachuteconsultingllc.com
713.501.7793
Individual Ergonomic Assessment
Date
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Time
:
Hours
Minutes
AM
PM
AM/PM
Company
*
Employee
*
First
Last
Date of Last Ergonomic Assessment
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Leave blank if employee has never had an ergonomic assessment.
Dominant Hand
*
Right
Left
Ambidextrous
Height
*
Office Location
*
Furniture
Desk at correct height?
*
Yes
No
Keyboard tray - right height?
*
N/A
Yes
No
Keyboard and mouse at the same level?
*
Yes
No
Three-way adjustable chair? (Or ergonomic chair?)
*
Yes
No
Chair adjusted as recommended?
*
Yes
No
Recommendations for Furniture
Computer Equipment
Monitor at correct height and in front of the employee?
*
Yes
No
What kind of mouse?
*
Traditional
Traditional with Track Ball
Ergonomic
Vertical Ergonomic
Joystick
Uses the computer pad
Ergonomic with Track Ball
Other
Is this mouse adequate?
*
Yes
No
Recommendations for computer equipment.
Accessories
Footrest?
*
No
Yes
Anti-glare screen?
*
No
Yes
Document holder?
*
No
Yes
Mouse wrist pad?
*
No
Yes
Keyboard wrist pad?
*
No
Yes
Floor mat?
*
No
Yes
Phone headset or headrest?
*
No
Yes
Computer glasses needed?
*
No
Yes
Recommendations for accessories.
General Office/Housekeeping
Bookshelves mounted safely to the wall?
*
Yes
No
N/A
Electrical cords neatly wrapped together and out of the way?
*
Yes
No
N/A
Phone close to employee for easy access?
*
Yes
No
N/A
Clutter on the desk or workspace?
*
Yes
No
Adequate workspace?
*
Yes
No
Frequently used items are easily accessible?
*
Yes
No
Recommendations for General Office/Housekeeping.
Workstation Setup Evaluation
Head
Is the employee's head directly over the shoulders?
*
Yes
No
N/A
Does the employee's head face straight forward?
*
Yes
No
N/A
Does the employee have to look down to see his/her work?
*
Yes
No
N/A
If the employee is reading/writing, is his/her work tilted up to prevent the head from tipping forward?
*
Yes
No
N/A
If the employee is performing data entry, is the document directly in front of him/her?
*
Yes
No
N/A
Neck
Does the employee cradle a telephone on his/her shoulder?
*
No
Yes
N/A
Is the employee's head tipped forward?
*
No
Yes
N/A
Is the monitor at a height that keeps the employee's neck in a neutral position?
*
No
Yes
N/A
Does the employee use bifocals or trifocals and tip his/her head back to focus?
*
No
Yes
N/A
Shoulders
Are the employee's shoulders relaxed?
*
No
Yes
N/A
Are the employee's upper arms next to the body?
*
No
Yes
N/A
Does the employee have to reach for materials?
*
No
Yes
N/A
Does the employee have to reach to operate equipment?
*
No
Yes
N/A
Is the work surface at the correct height for the employee?
*
No
Yes
N/A
Back
Does the chair provide good support to the employee's lower back?
*
No
Yes
N/A
Is the chair adjustable and is it adjusted to support the employee correctly?
*
No
Yes
N/A
Does the employee have to stand at a low work surface which causes him/her to have to bend forward?
*
No
Yes
N/A
Does the employee have to move heavy materials?
*
No
Yes
N/A
Arms and Wrists
Are the employee's forearms and wrists in a neutral position?
*
No
Yes
N/A
Is the keyboard at the correct height and angle for the employee?
*
No
Yes
N/A
Are the employee's arms supported by wrist rests or the chair arms?
*
No
Yes
N/A
Is the arm supported when using the mouse?
*
No
Yes
N/A
Legs and Feet
Are the employee's feet flat on the floor or a footrest
*
No
Yes
N/A
Is there clearance under the work surface for the employee's legs?
*
No
Yes
N/A
Does the chair put pressure on the back of the employee's lower legs?
*
No
Yes
N/A
Eyes
At what distance is the monitor from the employee's eyes?
*
<18"
18"
19"
20"
21"
22"
23"
24"
25"
26"
27"
28"
29"
30"
>30"
Are the brightness and contrast controls for the monitor set for comfortable viewing?
*
No
Yes
N/A
Is the screen clean?
*
No
Yes
N/A
Is the employee's eyeglass/contacts prescription up to date?
*
No
Yes
N/A
Is there reflected glare on the screen or surrounding flat surfaces?
*
No
Yes
N/A
Is there direct glare from windows or bright light fixtures?
*
No
Yes
N/A
Are ventilation ducts directed at the employee which may result in dry eyes?
*
No
Yes
N/A
If the employee uses a document holder, is it at the same height and distance as the monitor?
*
No
Yes
N/A
Recommendations for Workstation Set Up
Work Methods
Does this employee vary tasks throughout the day?
*
No
Yes
N/A
Does the employee do some work standing as well as sitting?
*
No
Yes
N/A
Is there an opportunity to rotate tasks to use different muscle groups?
*
No
Yes
N/A
Does the employee take periodic breaks throughout the day to stretch?
*
No
Yes
N/A
Does the employee know how to adjust his/her workstation to fit his/her body?
*
No
Yes
N/A
Is the work station adjusted properly?
*
No
Yes
N/A
What type of work does the employee do most? (data entry, word processing, etc)
How many hours per day does the employee spend on the computer (work and home)?
Employee Survey
For each body part listed, check the frequency of discomfort, numbness, or pain.
Eye Strain/Sore Eyes/Blurry Vision
*
Always
Often
Occasionally
Never
Neck
*
Always
Often
Occasionally
Never
Shoulders
*
Always
Often
Occasionally
Never
Arms
*
Always
Often
Occasionally
Never
Elbows
*
Always
Often
Occasionally
Never
Wrists/Hands
*
Always
Often
Occasionally
Never
Upper Back
*
Always
Often
Occasionally
Never
Lower Back
*
Always
Often
Occasionally
Never
Hips
*
Always
Often
Occasionally
Never
Knees
*
Always
Often
Occasionally
Never
Lower legs
*
Always
Often
Occasionally
Never
Ankles/Feet
*
Always
Often
Occasionally
Never
For body parts with any discomfort or pain, list what the employee does for treatment (OTC medication, stretching, etc.)
Exercise/Activities
Home Office Setup
Do you carry a laptop home?
No
Yes
If you do carry a laptop home, how often?
Would you like a rolling bag for your laptop?
No
Yes
Overall Recommendations
Assessment End Time
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Parachute Ergonomic Specialist
Sherri Luehr
Tara Gomez
Anna Welsch
Rebecca Gribben
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