Pain Injury RTW/Accommodation Interest/education Other	The worker is suffering from back pain	Eye Dominance: Left Right Hand Dominance: Left Right Height:
Equipment Inventory:
Chair:	Mouse:	Document Holder:	Other:
Keyboard:	Monitor(s):	Footrest:	Other:
Preferred Posture	Proper Adjustment/ Position/Posture	Action Required (for any No responses)
CHAIR	Yes	No
Thigh parallel to floor			raise/lowerchair add/removefootrest
Feet on floor			raise/lowerchair add/removefootrest limitshoeheelheight
Adequate back support			contactsupervisor toreview
Shoulders relaxed and level			adjust/eliminatearmrest raise/lowerchair raise/lower workstationheight raise/lowerkeyboard height
Elbows at 90			adjust/eliminatearmrest raise/lowerchair raise/lowerworkstation height raise/lowerkeyboardheight
2-3 finger breadth between back of knee and front edge of seat			adjustseatdepth
Seat pan padded			contactsupervisorto review chair
Does worker know how to operate chair			Review controls and/orinstructionmanual

DESK	Yes	No
Seated elbow height equal to desk height			raise/lowerchair raise/lowerworkstation
Adequate space			organize desktop surface remove clutter under desk arrange cabinet/pedestal to minimize body twisting
Minimal reaching above shoulder			Stand to reach overhead items Place frequently used items on desk
Minimal reaching below shoulder			arrange cabinet/pedestal for easy reach remove clutter from under desk
KEYBOARD	Yes	No
Relaxedarmposition duringkeyboarding			raise/lower keyboard height raise/lowerchairheight
Wristsinneutral flexion/ extension			recheckchairheight recheckkeyboardheight and tilt
Neutralwristdeviation			reviewtypingskills attainsplitkeyboard
Relaxedfingers			Relaxation exercises, stretches
Longitudinalfingerarch maintained			learnproperkeyboarding technique keep fingernails short
Uprightuppertorso			adjustkeyboardheight moveclosertokeyboard adjustchairheight adjustposture
Lighttouchtorkeyboard input			relaxation exercises reviewkeyboardfunctioning

MOUSE	Yes	No
Easyreach			move closer to work surface orient mouse closer to keyboard adjust mouse sensitivity usesensorpadonsplit keyboard
Wrist inneutralflexion/ extension			adjustmouse height convert mouse from dominant to non-dominant side obtain ergonomic mouse
MONITOR(S)	Yes	No
Head neutralposture			raise/lower monitor
Eyeslookingforward			orient screen in front orient document in front/beside monitor positioned for dominant eye
Monitor is arm'slength fromuser			adjust distance (forward/back)
Uppertorsorelaxed againstchairback			move monitor closer adjust posture
Documentand monitor same distance and height from eyes			adjust monitor and/or document position
Glare minimized			tilt monitor slightly down adjust monitor brightness close blinds contact Facilities for lighting adjustment use anti-glare screen use anti-glare/blue-light reduction glasses
TELEPHONE	Yes	No
Neck/head centered			recommend headset
Easyreach			orientphonecloser

JOB VARIETY	Yes	No
Visual rest every 20 minutes			20-20-20 rule
Regularstretchbreaks			Stretching guide
Alternatetaskschedule			Job rotation, task variety

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