Display Screen Equipment (DSE) Assessment form at my organisation

Display Screen Equipment (DSE) Assessment form
Purpose: To ensure your work environment is as comfortable and efficient as possible.
Who: All employees, including laptop users and home workers.
When: It is important to complete this assessment as a new starter, if you are experiencing discomfort or following a desk
change (where applicable).
What: Answer the questions carefully using the guidance sheet. Your line manager will follow up any issues identified.
Employee Name (print):
Line Manager Name (print): Location:
Employee signature: Date:
It’s important to read the attached DSE guidance notes before starting this assessment
General: Everyone should complete this section
I’ve read the attached DSE guidance so I can complete                                               Yes /No Comments
this assessment
I take regular breaks away from my computer, helping reduce                                 Yes/ No Comments
eye strain and I stretch regularly to stop tiredness
I know that LV= provides free eye sight tests every two years                                   Yes /No Comments
and I should speak to my manager if any visual problems affect
me and my work
I know that if I have a disability or injury which may affect my                              Yes /No Comments
workstation setup I should speak to my line manager
for further advice
Environment: Everyone should complete this section
My desk and area around me are clear of unused items freeing                               Yes /No Comments
up space to move and reduce the risk of slips, trips and falls
The lighting is suitable for me to comfortably work with                                              Yes/ No Comments
The office temperature is ok and I know I should wear clothing
that I can change to keep myself comfortable                                                                Yes /No Comments
Office based: People mostly based in an office should complete this section
I know how to setup and move my screen to the right height                                     Yes /No Comments
and distance away from me
I keep my screen clean, it’s free of glare/reflections and                                            Yes /No Comments
my keyboard is central to my screen
I’m comfortable using the computer software provided for my role                         Yes /No Comments
I know how to order a mouse mat, wrist rest or document holder
if I need one (only needed if you feel it will help your comfort)                                  Yes /No Comments
My desk is correctly set up for me to work and my equipment
is placed correctly on my desk to stop me having to stretch                                        Yes /No Comments
to reach it
My chair is in good condition and set at the right height to                                         Yes/ No Comments
allow my feet to touch the floor and the backrest supports
my upper body
Laptop users: Only complete this section if you use a laptop
I have a laptop docking unit on my desk allowing me to use                                       Yes /No Comments
a standard monitor and keyboard
I follow best practice when using my laptop away from my                                         Yes /No Comments
usual place of work
I follow best practice for moving and transporting my laptop                                     Yes /No Comments
Home workers: Only complete this section if you work from home
My home working equipment and environment is suitable for                                  Yes /No Comments
me to safely and comfortably carry out my job role
The equipment LV= has provided is set up correctly, maintained                              Yes /No Comments
in a good working condition and cables around me are secure
I am aware that should my equipment (including cables) become                             Yes /No Comments
damaged I should stop using it and contact my manager
for further advice