DSE Assessment Action Plan
Complete this form to record findings from a Display Screen Equipment (DSE) assessment and outline necessary actions for improvement.
Assessor's Full Name
*
First Name
Last Name
Employee Being Assessed
*
First Name
Last Name
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Department/Location
*
Workstation Assessment Table
*
Rows
Compliant
Needs Action
Not Applicable
Chair adjustment
1
2
3
Desk height
4
5
6
Monitor position
7
8
9
Keyboard/mouse arrangement
10
11
12
Lighting
13
14
15
Cables and trip hazards
16
17
18
Overall Risk Rating
*
1
2
3
4
5
Issues Identified (if any)
Recommended Actions
*
Person Responsible for Action
Target Completion Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Follow-Up Review Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Comments
Submit Action Plan
Should be Empty: