Workplace Ergonomics Self-Assessment Form

Workplace Ergonomics Self-Assessment Form — Form Fields

This operations template includes 10 fields. Allow employees to self-assess their workstation setup for ergonomic compliance before a formal review. Free to customize and use on ZenBuild.

• Employee Name (text, required)
• Email Address (email, required)
• Department (text, required)
• Workstation Location (text, required)
• Is Your Monitor at Eye Level? (multiple choice, required) — options: Yes, No, Unsure
• Is Your Chair Height Adjustable and Set Correctly? (multiple choice, required) — options: Yes, No, No Chair (Standing Desk)
• Do You Use a Keyboard Tray or External Keyboard? (multiple choice, required) — options: Yes, No
• Primary Discomfort Area (if any) (dropdown selection, required) — options: None, Neck, Shoulders, Lower Back, Wrists/Hands, Eyes, Other
• Additional Concerns or Requests (long text, optional)
• Would You Like an In-Person Ergonomic Review? (multiple choice, required) — options: Yes, No