Display Screen Equipment Self Assessment

Employee Name:
Task and/or Location:

DSE Use

Is the use of DSE a requirement of your work daily?
Yes No Do you use DSE for continuous spells of an hour or more?
Yes No Does your work involve using a laptop?
Yes No

Screen

Is the screen located in front of you?
Yes No Is the top of the screen level with your eyes?
Yes No Can the screen be tilted and adjusted?
Yes No Is the screen free of reflections?
Yes No

Keyboard and Mouse

Can the keyboard be moved comfortably?
Yes No Is there sufficient wrist rest space?
Yes No Are the keyboard symbols legible?
Yes No Can you operate the mouse without reaching?
Yes No Can you operate the mouse with hand/wrist on desk?
Yes No Is there enough space for the mouse?
Yes No

Chair

Is the height of the chair adjustable?
Yes No Is the backrest adjustable?
Yes No Do you know how to adjust the chair?
Yes No Is the chair fitted with arms?
Yes No Do the chair arms contact the desk when adjusted?
Yes No

Desk

Is there enough work surface?
Yes No Is there adequate knee room?
Yes No

General

Is there adequate lighting?
Yes No Are there breaks from DSE use?
Yes No

Posture

Are your upper arms aligned with your body?
Yes No Are your wrists straight when typing?
Yes No Is your back supported by the chair’s backrest?
Yes No Are your feet comfortably on the floor?
Yes No

Eye Tests

Have you had an eye test for DSE use?
Yes No

Personal

Do you have wrist aches/pains?
Yes No Do you have forearm aches/pains?
Yes No Do you have neck aches/pains?
Yes No Do you have eye aches/pains?
Yes No Do you have back aches/pains?
Yes No Have you ever suffered from epilepsy?
Yes No

Additional Comments

Please provide any additional information or comments: