INITIAL ERGONOMICS RISK ASSESSMENT CHECKLIST

ERGONOMICS AND MUSCULOSKELETAL PAIN / DISCOMFORT COMPLAINT FORM

(Refer the google form)

This form can be filled out by any employee of the company/organization. This form should be
used for any work-related complaints on physical ergonomics and musculoskeletal
disorders/pain. Ergonomics problems include any workstation or work practices which could
contribute to musculoskeletal disorder/pains.

Date: ______________________ Staff ID No: _______________________

Name: ______________________ Job tasks/title: _____________________
Department: _________________
Contact No: __________________

Please briefly describe the nature of the complaint and any potential cause.
1) What is the nature/main of the problem?

2) Where is the problem first experienced?

3) When was the problem first experienced?

If we need to contact you to discuss your complaints, when is the best time to reach you?

So that we can respond promptly, please return this form to:

(Name of the trained person)
(Email & contact No of the trained person)

(Do not write anything in this section below. To be filled by trained pearson only)

Is the nature of the complaint ergonomics-related? Yes____ No____

Action taken: Investigation/Others (Specify action taken/closed file)