Fillable Fy14 Sh-26336-sh4 Ergonomic-Assessment-Checklist Ergonomic-Assessment-Checklist

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Fy14 Sh-26336-sh4 Ergonomic-Assessment-Checklist Ergonomic-Assessment-Checklist

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Ergonomic Assessment
Checklist
Date
Activity Assessed
Risk Ratting (circle one)
Organization
Point of Contact
High Medium Low
Personnel Observed
*See Notes on bottom of form to obtain the Rating*
BLDG NO/Location
ROOM/AREA
Ergonomic Assessment Checklist
Yes
No
*Note if there is a Yes checked in any block please use
page two to give a brief explanation of what the activity
is or what the worker complaint was.
High Risk: If you answered Yes to #1 (and the shop has done nothing
to fix it), if Yes to #2 or 3 and two other Yes's in #'s 4 through 15, or if
Yes to six or more in #'s 4 through 15.
Medium Risk: If you answered Yes to #1 (and the shop has made
changes), if Yes to #2 or 3 and one other Yes in #'s 4 through 15, or if
Yes to three to five in #'s 4 through 15.
Low Risk: If no Yes's in #'s 1, 2, or 3 and less than 3 Yes's in #'s 4
through 15.
Ergonomic Survey Evaluation
Date
Activity Assessed
Ergonomic Survey Checklist Evaluation Explanation
Question
number
&
Activity Name
Brief Explanation – use this section if you answered yes to any questions on page 1
(please list corresponding question number) and briefly outline any risks associated
with an activity
Risk Factors
Name of Assessor
Name of Reviewer
This material was produced under grant SH26336SH4 from the Occupational Safety and Health Administration, U.S. Department of
Labor. It does not necessarily reflect the views or policies of the U.S. Department of Labor, nor does mention of trade names, commercial
products, or organizations imply endorsement by the U.S. Government
Risk Factor Guide
Head & Neck
Optimal work
Position
0
0
to 10
0
Moderate Stress
10
0
to 15
0
Severe Stress
15
0
to 20
o
Elbow Angle
Optimal work
position
90
0
to 105
0
Moderate Stress
105
0
to 120
0
Severe Stress
120
0
to 135
0
Elbow Abduction
Optimal work
position
0
0
to 10
0
Moderate stress
10
0
to 20
0
Severe Stress
20
0
to 30
0
Wrist Flexion
Optimal work
position
0
0
to 15
0
Moderate stress
15
0
to 30
0
Severe Stress
30
0
to 40
0
Wrist Extension
Optimal work
Position
0
0
to 15
0
Moderate stress
20
0
to 35
0
Severe stress
35
0
to 45
0
Hip/Lower Back
Flexion
Optimal work position
0
0
to 5
0
Moderate stress
5
0
to 10
0
Severe stress
10
0
to 15
0
Reaching
Optimal work position
Male: 10” to 15”
Female: 8” to 12”
Moderate stress
Male 15” to 20”
Female 12” to 16”
Severe stress
Male: 20” to 25”
Female: 16” to 20”
Task Height
Optimal work position
Male: 36” to 39”
Female: 35” to 38”
Moderate stress
Male: 39” to 41”
Female: 38” to 40”
Severe Stress
Male: 41” to 43”
Female: 40” to 42”
Workstation Height
Optimal work position
PRECISION WORK
Male: 40” to 44”
Female: 38” to 42”
Optimal work position
SMALL, LIGHT WORK
Male: 36” to 38”
Female: 34” to 36”
Optimal work position
LARGE, HEAVY WORK
Male: 30” to 36”
Female: 28” to 34”
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Completed 16 November 2019

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