Ergonomics Worksite Evaluation Form

The following job, process, or operation: was evaluated on to identify potential exposures to repetitive motion injuries (RMIs) and determine the methods to be used to control or minimize the exposures.

Every reasonable effort will be made to timely correct identified exposures that may have caused RMIs or, if the exposure is not capable of being corrected, to minimize the identified exposure to the extent feasible. Engineering controls, such as work station redesign, adjustable fixtures, and tool redesign, as well as administrative controls, such as job rotation, work pacing, and alternative work breaks, will be considered to control or minimize the exposure.

Potential exposure: Method used to control or minimize exposure:

Describe how and when each exposure was corrected or, if the exposure is not capable of being corrected, why it cannot be corrected and how it will be minimized to the extent feasible:

Worksite evaluation completed by (print name):

Signature of evaluator: Date:

Approved by (print name & title):

Approval signature: Date:

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