/ WHS FORM / WHS29
WORKING FROM HOME
SAFETY AND ERGONOMIC SELF-ASSESSMENT
NOTE: This form supports WHS Form 52 and the Working From Home Procedure.
Workplace: / Date:

PERSONAL DETAILS

Employee family name: / Given name:
Contact phone no: / (w) / (h)
Employee number: / Occupation: / Campus:
Division/Portfolio: / School/Unit/Institute/Centre:
Line Manager:
Address of home work environment:
The Employee must indicate a Yes or No response to the following where applicable and ensure a written response where required.
Where a No response is indicated, the employee is responsible to rectify the matter or discuss a reasonable solution with their line manager.
This form must accompany WHS Form 52 – Working From Home Formal Agreed Arrangement.

WORKSTATION (if applicable)

/ YES / NO / COMMENTS
Refer to the correct ergonomic setup provided on page 2 below when setting up your home workstation.
CHAIR
Is the chair fully adjustable to achieve optimum support? (Height, tilt, and backrest).
Is the chair on a carpeted surface?
If no, has a piece of carpet or similar been placed underneath the chair to reduce the sudden movement of the chair when getting on and off?
Can you get close to the workstation without impediment? (Check that chair arms are not in the way and there is clear legroom).
Desk/Keyboard/MOUSE
Is desk height or keyboard height adjustable?
If yes, is the desk height in the range of 580-730 mm?
If not adjustable, is a footrest required to support both feet where you cannot place them flat on the floor?
Are your forearms parallel with the floor or angled slightly downward and elbows by your side when using the keyboard? (This can be achieved by lowering the desk to suit the user, or with a fixed desk, raising the chair).
Is there sufficient space to move your legs under the desk?
Is a document holder required? (For frequent reference to hard copy documents).
Does the mouse fit comfortably in the palm of the hand?
Is the mouse positioned close to you so that your elbows are maintained by your side?
Screen
Is the screen set in front of you when in a seated position?
When seated and looking straight ahead, is your horizontal line of sight at the top edge of the screen to maintain the neck in the neutral position? (Avoid looking up or downwards for prolonged periods).
Is the screen at a comfortable reading distance – at least an arm’s length when seated?
Layout
Are frequently used items within easy reach? (Avoid frequent overreaching.)
Is there sufficient space for all materials/equipment?
Work Environment
Is the lighting comfortable for the task to reduce the risk of eye strain)?
Are noise levels conducive to working effectively without distraction?
Is the temperature and airflow in the room comfortable?
Electrical
Are power circuits protected by a Residual Current Device (RCD)?
Security
Describe the arrangements for your security, the security of equipment and the confidentiality of files.
OTHER EQUIPMENT (if applicable)
Is the WorkPace Ergonomic Software to be installed to ensure adequate breaks?

Employee declaration:

I verify that the information provided in this working from home application is a true and accurate record.

Employee’s signature / Date:
Line Manager’s signature / Date:

For further health and safety information, contact Safety and Wellbeing Unit on 8302 2459.

RECOMMENDED WORKSTATION SETUP

WHS29 Ergonomics Self-Assessment V 1.2 June 2013 Safety and Wellbeing Team

Disclaimer: Hardcopies of this document are considered uncontrolled. Please refer to the Safety and Wellbeing website for the latest version