The DSE Form Template UK is offered in multiple formats, including PDF, Word, and Google Docs, featuring customizable and printable examples.
Dse Form Template UK Editable – PrintableSample
DSE Form Template UK 1. Employee Information 2. Workstation Details 3. Assessment Date 4. Display Screen Equipment (DSE) Usage 5. Job Role and Responsibilities 6. Workstation Setup 7. Breaks and Rest Periods 8. Health and Safety Concerns 9. Recommendations for Improvement 10. Declaration and Signature 11. Signatures
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WORD
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[Name of the Applicant]
[Applicant’s ID]
[Applicant’s Address]
[Applicant’s Phone]
[Applicant’s Email]
[Name of the Employer]
[Employer’s ID]
[Employer’s Address]
[Employer’s Phone]
[Employer’s Email]
This form serves to collect essential information for the DSE (Display Screen Equipment) assessment in accordance with UK regulations, aimed at ensuring the health and safety of users who regularly work with display screen equipment.
The Applicant’s job role is described as follows: [Detailed job description including specific duties and responsibilities related to the use of display screen equipment].
The Applicant regularly uses the following equipment: [List all equipment, including type of computer, monitor specifications, peripherals, etc.].
The workstation comprises: [Describe the workstation layout, including desk height, chair type, arrangement of monitors, and other relevant details].
The Applicant should report any health issues related to display screen use. Current issues include: [List any existing health concerns, e.g., eye strain, musculoskeletal issues].
The Applicant confirms they have received training on DSE safety and ergonomics and has access to ongoing support: [Details of any training received or resources available].
[Signature of the Applicant]
[Name of the Applicant]
[Signature of the Employer]
[Name of the Employer]
[Name of the Employee]
[Employee ID]
[Employee’s Address]
[Employee’s Phone]
[Employee’s Email]
[Company Name]
[Company ID]
[Company Address]
[Company Phone]
[Company Email]
This DSE form is intended to ensure compliance with the Health and Safety (Display Screen Equipment) Regulations 1992, through gathering required information about workstation setup and potential risks.
The Employee’s job is defined as: [Provide a detailed description of tasks performed using display screen equipment].
The following display screen equipment is utilized: [Include details about the make and model of the monitor, laptop, keyboard, and any other peripherals].
The workstation setup is evaluated as: [Explain ergonomic considerations including chair type, screen height relative to eye level, and desk arrangement].
Employees should declare any health conditions linked to DSE use. Current issues include: [List any health issues reported].
The Employee affirms they have received adequate training on DSE safety practices and ergonomics: [Details about training programs attended].
[Signature of the Employee]
[Name of the Employee]
[Signature of the Company Representative]
[Name of the Company Representative]
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