Page 1 of 4

Display Screen Equipment Assessment

First Name(*)

Enter your First Name

Last Name(*)

Enter your Last Name

Job Title(*)

Enter your Job Title

Location(*)

Enter your Location

Email(*)

Invalid email address.

Employee Questions

How long have you worked with VDUs?(*)

Please enter a period of time

How many continuous hours do you spend inputting at the keyboard each day?(*)

Please enter a value

Do you take regular breaks (5/10 mins in every 50/60 mins) of continuous use?(*)

Please give an answer

Conditions

Are you conscious of any of the following conditions during or upon completion of your work? If so, please indicate an approximate date when you first became aware of the condition.

Pain or swelling in the hand, wrist(*)

Pain or swelling in the hand, wrist

Yes

Please select an option

Approximate date your were first aware(*)

Please select a date

Have you experienced numbness or a ‘pins and forearm, neck or shoulders, pins and needles’ sensation in the hands or arms?(*)

Have you experienced numbness or a ‘pins and forearm, neck or shoulders, pins and needles’ sensation in the hands or arms?

Yes

Please select an option

Approximate date your were first aware(*)

Please select a date

Eye Strain - Have you received a VDU vision test?(*)

Eye Strain - Have you received a VDU vision test?

Yes

Please select an option

Date of VDU test(*)

Please select a date

Eye Strain - Do you wear corrective glasses for VDU?(*)

Eye Strain - Do you wear corrective glasses for VDU?

Yes

Please select an option

Approximately how long have you worn corrective glasses?(*)

Please indicate how long

Do you suffer from discomfort in other areas of the body?(*)

Do you suffer from discomfort in other areas of the body?

Yes

Please select an option

Please Describe(*)

Please describe

Have you consulted your GP with any of these complaints?(*)

Have you consulted your GP with any of these complaints?

Yes

Please select an option

Have you been absent from work as a result?(*)

Have you been absent from work as a result?

Yes

Please select an option

Please state if you use a keyboard, typewriter or play a musical instrument at home or have any other hobby that requires repetitive hand or arm movements?(*)

Please indicate other hobbies etc

Your Equipment

Display Screen and Keyboard

Can the keyboard be tilted, having a matt surface with symbols clearly legible?(*)

Can the keyboard be tilted, having a matt surface with symbols clearly legible?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Is the screen image clear, stable and easy to read?(*)

Is the screen image clear, stable and easy to read?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Is the brightness / contrast easily adjustable?(*)

Is the brightness / contrast easily adjustable?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Does the screen swivel and tilt easily?(*)

Does the screen swivel and tilt easily?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Is the screen height comfortable?(*)

Is the screen height comfortable?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Is the screen free from distracting or uncomfortable reflection or glare?(*)

Is the screen free from distracting or uncomfortable reflection or glare?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Is there a screen cleaning kit available?(*)

Is there a screen cleaning kit available?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Is the software easy to use and suited to your tasks?(*)

Is the software easy to use and suited to your tasks?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Is the user able to take regular breaks during the working shift?(*)

Is the user able to take regular breaks during the working shift?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Has the user been made aware of the possible risks when using Display Screen Equipment?(*)

Has the user been made aware of the possible risks when using Display Screen Equipment?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Does the user look away from the screen periodically to refocus eyes and avoid eye strain, i.e. every 10/15mins of continuous use?(*)

Does the user look away from the screen periodically to refocus eyes and avoid eye strain, i.e. every 10/15mins of continuous use?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Does the user keep eyes moist by blinking frequently when using DSE?(*)

Does the user keep eyes moist by blinking frequently when using DSE?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Has the user been given information or training on safe working with DSE?(*)

Has the user been given information or training on safe working with DSE?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Does the user find the information / training helpful and feel confident in carrying out their duties safely?(*)

Does the user find the information / training helpful and feel confident in carrying out their duties safely?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Your Workplace

Posture and Musculoskeletal Issues

Chair

Does the chair have a “5 star” base?(*)

Does the chair have a “5 star” base?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Is the chair stable, allowing the person to sit comfortably with freedom of movement?(*)

Is the chair stable, allowing the person to sit comfortably with freedom of movement?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Is the height of the seat adjustable?(*)

Is the height of the seat adjustable?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Can the back of the chair be adjusted in both height and tilt (giving adequate lumbar support)?(*)

Can the back of the chair be adjusted in both height and tilt (giving adequate lumbar support)?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

When the chair has been adjusted to a height permitting a correct keying posture, can feet be placed flat on the floor?(*)

When the chair has been adjusted to a height permitting a correct keying posture, can feet be placed flat on the floor?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Is a footrest required?(*)

Is a footrest required?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Work Surface and Associated Equipment

Does the desk top have a sufficiently large surface to allow a flexible arrangement of screen, keyboard and related equipment/paperwork?(*)

Does the desk top have a sufficiently large surface to allow a flexible arrangement of screen, keyboard and related equipment/paperwork?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Is there adequate space for the user to vary movements to find a comfortable working position?(*)

Is there adequate space for the user to vary movements to find a comfortable working position?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Is the document holder stable and easily adjustable?(*)

Is the document holder stable and easily adjustable?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Is there space for the user to rest their arms when not keying?(*)

Is there space for the user to rest their arms when not keying?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Are there any reflections from the work surface or associated equipment which causes discomfort?(*)

Are there any reflections from the work surface or associated equipment which causes discomfort?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

General Issues

Lighting - Natural/Artificial

Is the general level of lighting suitable for working on your Display Screen Equipment? (300-500 LUX)(*)

Is the general level of lighting suitable for working on your Display Screen Equipment? (300-500 LUX)

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Are windows fitted with suitable blinds and are they effective in controlling sunlight/glare?(*)

Are windows fitted with suitable blinds and are they effective in controlling sunlight/glare?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Environmental Issues

Noise

Are there any distracting noises (e.g. from other equipment)?(*)

Are there any distracting noises (e.g. from other equipment)?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Electrical

Are there any electrical hazards such as damaged cables or overloaded sockets?(*)

Are there any electrical hazards such as damaged cables or overloaded sockets?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Are there any loose or trailing cables or objects around the workstation which may present a trip hazard?(*)

Are there any loose or trailing cables or objects around the workstation which may present a trip hazard?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Heating / Cooling

Is the temperature & humidity at your workstation comfortable?(*)

Is the temperature & humidity at your workstation comfortable?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Ventilation

Is ventilation adequate without too much heat or draught?(*)

Is ventilation adequate without too much heat or draught?

Yes

Please select an option

Comments or Action Required

Please enter comments/action

Your Signature(*)

Sign Above

Please sign this field

Today's Date(*)

Please select today's date