HFORM11: Display Screen Equipment (DSE) Self-Assessment¶
Form Reference: HFORM11 Version: 1.0 Classification: CRGI Information Form Owner: Sean Ashton, Operations Manager Purpose: Enable staff to self-assess their workstation ergonomics and identify DSE-related risks per Health and Safety (Display Screen Equipment) Regulations 1992 (amended 2002) and HPOL21. Supports home worker and office-based risk assessment obligations under RA003.
Document Control¶
| Version | Date | Author | Changes |
|---|---|---|---|
| 1.0 | 10/03/2026 | Sean Ashton | Initial creation |
1. Staff & Workstation Details¶
| Field | Details |
|---|---|
| Staff Name | ________________ |
| Role/Position | ________________ |
| Department | ________________ |
| Assessment Date | ________________ |
| Location Type | ☐ Home Office ☐ Client Site ☐ Shared Workspace ☐ CRGI Office |
| Home Address (if home-based) | ________________ |
| Hours per week at DSE | ____ hours |
| Date of Last Assessment | ________________ |
2. Display Screen Assessment¶
For each item, select: ☐ Yes ☐ No ☐ N/A
| Item | Compliant | Issue Identified | Comments |
|---|---|---|---|
| Screen brightness is adjustable | ☐ | ☐ | ________________ |
| No flicker or instability visible | ☐ | ☐ | ________________ |
| Screen is clean and free from glare | ☐ | ☐ | ________________ |
| Screen size is suitable for work | ☐ | ☐ | ________________ |
| Image is stable and clear | ☐ | ☐ | ________________ |
| Characters well-defined and legible | ☐ | ☐ | ________________ |
| Screen separate from keyboard | ☐ | ☐ | ________________ |
| Screen positioned at arm's length | ☐ | ☐ | ________________ |
| Top of screen at or below eye level | ☐ | ☐ | ________________ |
Overall Screen Status: ☐ Adequate
☐ Requires adjustment
☐ Replacement needed
3. Keyboard & Input Device Assessment¶
| Item | Compliant | Issue Identified | Comments |
|---|---|---|---|
| Keyboard separate from screen | ☐ | ☐ | ________________ |
| Keyboard tiltable and adjustable | ☐ | ☐ | ________________ |
| Keys are legible | ☐ | ☐ | ________________ |
| Mouse/trackpad suitable for role | ☐ | ☐ | ________________ |
| Space available to move mouse | ☐ | ☐ | ________________ |
| Keyboard positioned at elbow height | ☐ | ☐ | ________________ |
| Wrist support/rest available | ☐ | ☐ | ________________ |
| No awkward hand/wrist positions required | ☐ | ☐ | ________________ |
Overall Keyboard/Input Status: ☐ Adequate
☐ Requires adjustment
☐ Replacement needed
4. Chair & Desk Assessment¶
Seat & Back Support¶
| Item | Compliant | Issue Identified | Comments |
|---|---|---|---|
| Chair seat height is adjustable | ☐ | ☐ | ________________ |
| Seat back support adjustable | ☐ | ☐ | ________________ |
| Back support positioned at lumbar region | ☐ | ☐ | ________________ |
| Seat width/depth adequate | ☐ | ☐ | ________________ |
| 5-castor base provides stability | ☐ | ☐ | ________________ |
| Footrest available (if needed) | ☐ | ☐ | ________________ |
| Seat height: feet flat on floor/rest | ☐ | ☐ | ________________ |
| Adequate space around chair | ☐ | ☐ | ________________ |
Desk & Work Surface¶
| Item | Compliant | Issue Identified | Comments |
|---|---|---|---|
| Desk surface area is adequate | ☐ | ☐ | ________________ |
| Desk height allows 90° elbow angle | ☐ | ☐ | ________________ |
| Work surface is matt (non-reflective) | ☐ | ☐ | ________________ |
| Desk height is adjustable (if standing) | ☐ | ☐ | ________________ |
| Sufficient space for equipment/documents | ☐ | ☐ | ________________ |
| Document holder available (if needed) | ☐ | ☐ | ________________ |
Overall Furniture Status: ☐ Adequate
☐ Requires adjustment
☐ Replacement needed
5. Environmental Conditions Assessment¶
| Item | Compliant | Issue Identified | Comments |
|---|---|---|---|
| Adequate lighting (no shadows on screen) | ☐ | ☐ | ________________ |
| No direct screen glare from windows | ☐ | ☐ | ________________ |
| No backlight creating screen glare | ☐ | ☐ | ________________ |
| Temperature is comfortable | ☐ | ☐ | ________________ |
| Humidity level is adequate | ☐ | ☐ | ________________ |
| Noise levels are acceptable | ☐ | ☐ | ________________ |
| Air circulation/ventilation adequate | ☐ | ☐ | ________________ |
| No distracting sources of noise | ☐ | ☐ | ________________ |
Overall Environment Status: ☐ Adequate
☐ Requires adjustment
☐ Significant concerns
6. DSE Usage & Health Patterns¶
Daily Usage & Work Patterns¶
| Field | Details |
|---|---|
| Hours per day at DSE | ____ hours |
| Typical work pattern | ☐ Continuous ☐ Mixed with non-DSE tasks ☐ Breaks between sessions |
| Break frequency | ☐ Every 30 minutes ☐ Every hour ☐ Every 2 hours ☐ Rarely/No breaks |
| Duration of breaks | ____ minutes |
| Away from screen activities | ☐ Walking ☐ Meetings ☐ Manual tasks ☐ Exercise ☐ Other: ________ |
Health & Wellness Check¶
Do you experience any of the following symptoms? (Select all that apply)
☐ Eye strain or tired eyes ☐ Headaches ☐ Neck or shoulder pain/tension ☐ Upper back pain ☐ Lower back pain ☐ Wrist or hand pain ☐ Fatigue or general tiredness ☐ None of the above
When do symptoms occur?
☐ During work at DSE ☐ End of working day ☐ Following days off ☐ Intermittent/unpredictable ☐ No symptoms
Severity of any symptoms:
☐ Mild (discomfort only) ☐ Moderate (affecting work/comfort) ☐ Severe (significantly impacts work/daily life) ☐ N/A – No symptoms
Has any DSE-related health issue caused time off work? ☐ Yes
☐ No
If yes, number of days: ____
7. Additional Workstation Concerns¶
Other issues or concerns about your workstation:
Do you have any physical conditions that may affect DSE working? (e.g., pregnancy, injury, medical condition)
☐ Yes – Please specify: ________________________________________________________________ ☐ No
Have you received DSE training?
☐ Yes – Date completed: __________ ☐ No – Training needed ☐ Refresher required
8. Photographic Evidence¶
Workstation photograph attached: ☐ Yes
☐ No
If yes, photo shows: ☐ Full workstation view (desk, chair, screen, keyboard) ☐ Screen position relative to seating ☐ Keyboard/mouse position ☐ Lighting/environmental conditions ☐ Any identified issues
Photo reference: ________________ Upload date: __________________
9. Actions Required¶
| Issue Identified | Action Required | Owner | Target Date | Cost Est. | Status |
|---|---|---|---|---|---|
| ________________ | ☐ Adjust ☐ Procure ☐ Repair ☐ Replace |
________________ | __________ | _____ | ☐ New ☐ In-Progress ☐ Complete |
| ________________ | ☐ Adjust ☐ Procure ☐ Repair ☐ Replace |
________________ | __________ | _____ | ☐ New ☐ In-Progress ☐ Complete |
| ________________ | ☐ Adjust ☐ Procure ☐ Repair ☐ Replace |
________________ | __________ | _____ | ☐ New ☐ In-Progress ☐ Complete |
Priority adjustments required: ☐ Yes
☐ No
10. Management Review¶
Assessment reviewed by: ________________ Date: __________________
Management assessment:
Workstation risk level: ☐ Low
☐ Medium
☐ High
Recommended actions:
Further assessment required: ☐ Yes – Type: ________________
☐ No
Specialist assessment (occupational health) required: ☐ Yes
☐ No
If yes, referral date: __________ Specialist: __________________
HREG06 (Home Worker & DSE Register) Updated:
☐ Yes – Entry Reference: ________________ Date: __________________ ☐ No – Will be updated by: ________________
Next assessment due: __________________
11. Staff Sign-Off¶
| Role | Name | Signature | Date |
|---|---|---|---|
| Staff Member (Self-Assessment) | ________________ | ________________ | __________ |
| Management Reviewer | ________________ | ________________ | __________ |
| Occupational Health (if referred) | ________________ | ________________ | __________ |
12. Notes & Follow-up Actions¶
Staff comments on assessment:
Manager follow-up actions:
Next review date: __________________
RETENTION: 3 years (or until workstation replaced) STORAGE: HREG06 Home Worker & DSE Register + Secure SharePoint – /HSQEMS/DSEAssessments/ ACCESS: Staff member, Operations Manager, Occupational Health (if referred), Health & Safety CLASSIFICATION: CRGI Information
Related Risk Assessment: RA003 – Home Worker & DSE Risk Assessment
END OF FORM