DSE Workstation Safety Checklist Form
Use this form to review a display screen equipment workstation for safety, ergonomics, and any corrective actions needed.
Workstation Details
Workstation Identifier
*
Department / Area
*
Assessor Name
*
First Name
Middle Name
Last Name
Checklist Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Safety Checklist
Screen height and position
*
Compliant
Needs Attention
Not Applicable
Keyboard and mouse reach
*
Compliant
Needs Attention
Not Applicable
Chair support and posture
*
Compliant
Needs Attention
Not Applicable
Desk and workspace clearance
*
Compliant
Needs Attention
Not Applicable
Lighting and glare control
*
Compliant
Needs Attention
Not Applicable
Cable management and trip hazards
*
Compliant
Needs Attention
Not Applicable
Breaks and ergonomic practices
*
Compliant
Needs Attention
Not Applicable
Findings and Follow-up
Hazards or issues found
Follow-up status
*
Please Select
No follow-up needed
Monitor
Action required
Escalate
Submit Checklist
Should be Empty: