Penkridge Parish Council
Display Screen Equipment
Name:
Job Title: Date:
1. Does your job involve the use of display screen equipment (DSE) ie: A computer with a visual display unit (VDU) or a process control screen or microfiche?
YES/NO
If the answer to question 1 is “No” then thank you for your co-operation
Please return this form to the Parish Administrator. If the answer is YES
please complete the rest of the form.
2. Is the use of the above equipment one of the primary functions of your job?
YES/NO
3. How often do you use the above equipment (Please tick one box)
Every working day without fail Most working days
About once a week Occasionally
4. On average how many hours a day do you work with the above equipment
(Please tick one box)
More than four hours About 2 – 4 hours
About 1 – 2 hours Less than 1 hour
5. Do you have a choice as to whether you have to use some kind of display screen equipment as part of your job?
YES/NO
6. Is it important that you have special keyboard skills to do your job YES/NO
7. Do you have other tasks that allow you to work away from the screen
On a regular basis throughout the day?
YES/NO
The following scoring system should be used in conjunction with the questionnaire. If an individual scores 90 or more, they should be considered a “User”.
1
Yes
10 points
No
0 points
2
Yes
20 points
No
0 Points
3
Every day
Once a week
40 points
5 points
Most days
Occasionally
20 points
0 points
4
4 hours +
1 – 2 hours
40 points
10 points
2 – 4 hours
< 1 hour
20 points
0 points
5
Yes
0 points
No
20 points
6
Yes
20 points
No
0 points
7
Yes
0 points
No
20 points
Total Score
If score is 90 + then please hand to the Parish Administrator, who may authorise you to have an eyesight test at the chosen optical provider of the Council.
To be completed by the Parish Administrator
Name ………………………………………………………. Signature ……………………………………………..
Date ……………………………………………………
