Forms

Centers for Disease Control

and Prevention

National Institute for Occupational 

Safety and Health
ErgoMine 2.0 Forms

This document contains five forms to assess hand tools, manual tasks, task risk factors,

task improvements, and musculoskeletal symptoms. The forms are based on risk factors 

for musculoskeletal disorders. The forms have been adapted from a previous NIOSH 

publication. 
Overview

The five forms contained in this document are adapted from NIOSH IC 9509 Ergonomics 

Processes: Implementation Guide and Tools for the Mining Industry1

(https://www.cdc.gov/niosh/mining/works/coversheet597.html). The purpose of these

forms from NIOSH IC 9509 along with a reference to the original document (NIOSH IC 

9509) are provided below. Please refer to the original document (NIOSH IC 9509) for 

detailed instructions on when and how to use the forms.

1. Hand Tool Checklist1a – To evaluate and compare design features of hand tools.

2. Musculoskeletal Discomfort Form1b – To identify the presence of discomfort by body

part experienced by workers.

3. Risk Factor Reporting Card1c – To encourage employee participation in the

ergonomics process by providing a reporting mechanism for potential risk factor

exposures and any body discomfort that may be related to the exposure.

4. Manual Task Assessment1d – To conduct a risk assessment of risk factor exposures

associated with manual tasks.

5. Ergonomic Task Improvement Form1e – To provide an effective method to highlight

interventions implemented to reduce or eliminate ergonomic risk factor exposures.

1 NIOSH [2009]. Ergonomics processes: implementation guide and tools for the mining industry. By Torma-Krajewski J, 

Steiner LJ, Burgess-Limerick R. Pittsburgh, PA: U.S. Department of Health and Human Services, Centers for Disease Control 

and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2009-107 (IC 9509). 

a Section IV. Implementation Tools; Tool E: Hand Tool Checklist; Page 30

b Section IV. Implementation Tools; Tool B: Musculoskeletal Discomfort Form; Page 9

c Section IV. Implementation Tools; Tool A: Risk Factor Report Card; Page 4

d Section IV. Implementation Tools; Tool F: Manual Task Risk Assessment; Page 33

e Section IV. Implementation Tools; Tool G: Ergonomic Task Improvement Form; Page 38
ErgoMine 2.0 Forms

Hand Tool Checklist...........................................................................................................................................Page 1

Musculoskeletal Discomfort Form ....................................................................................................................Page 3

Risk Factor Reporting Card ................................................................................................................................Page 4

Manual Task Assessment ..................................................................................................................................Page 5

Ergonomic Task Improvement Form.................................................................................................................Page 7
Hand Tool Checklist: Page 1

Hand Tool Checklist 

Evaluation Completed By________________________________ Date_________________________ 

Task_______________________________________________________________________________ 

Tool 1 (Describe)_______________________ Manufacturer________________ Model___________ 

Tool 2 (Describe)_______________________ Manufacturer________________ Model___________ 

Questions Tool 1 Tool 2

Does the tool: 

Reduce exposure to localized vibration? 

Reduce hand forces? 

Reduce/eliminate bending or awkward postures of the wrist? 

Avoid pinch grips? 

Is tool evenly balanced? 

Does tool grip/handle prevent slipping during use? 

Is tool equipped with handle that: 

Does not end in palm? 

Is made of textured, nonconductive material? 

Has a grip diameter suitable for most workers (or different size 

handles available)? 

Is made of padded or semipliable material? 

Is free of ridges, flutes or sharp edges? 

Can tool be used safely with gloves? 

Can tool be used by either hand? 

Can trigger be operated by more than one finger to avoid

fatigue? 

Does tool minimize twist or shock to hand? (in particular, 

observe reaction of power tools due to torque) 

 Yes  No  NA  Yes  No  NA

 Yes  No  NA  Yes  No  NA

 Yes  No  NA  Yes  No  NA

 Yes  No  NA  Yes  No  NA

 Yes  No  NA  Yes  No  NA

 Yes  No  NA  Yes  No  NA

 Yes  No  NA  Yes  No  NA

 Yes  No  NA  Yes  No  NA

 Yes  No  NA  Yes  No  NA

 Yes  No  NA  Yes  No  NA

 Yes  No  NA  Yes  No  NA

 Yes  No  NA  Yes  No  NA

 Yes  No  NA  Yes  No  NA

 Yes  No  NA  Yes  No  NA

 Yes  No  NA  Yes  No  NA

Total the number of Yes, No and NA responses __Yes __No __NA __Yes __No __NA
Hand Tool Checklist: Page 2

Are there any other positive features for each tool not listed above?

Tool 1 Tool 2
Musculoskeletal Discomfort Form: Page 3

Musculoskeletal Discomfort Form

Employee ID:____________ Job/Position: ________________________ Gender: M F Age: _______ Height: _____ ft._____ in. Weight: ________ lbs.

How long have you been doing this job? _____years _____ months How many hours do you work each week? ________ 

How to answer the questionnaire:

Picture: In this picture you can see the approximate 

position of the parts of the body referred to in the 

table. Limits are not sharply defined, and certain 

parts overlap. You should decide for yourself in 

which part you have or have had your trouble (if 

any). 

Table: Please answer by putting an "X" in the appropriate box - one "X" for each question. You may be in 

doubt as to how to answer, but please do your best anyway. Note that column 1 of the questionnaire is 

to be answered even if you have never had trouble in any part of your body; columns 2 and 3 are to be 

answered if you answered yes in column 1.

To be answered by everyone To be answered by those who have trouble

Have you at any time during the last 12 

months had trouble (ache, pain, discomfort, 

numbness) in: 

Have you at any time during the last 12 

months been prevented from doing 

your normal work (at home or away 

from home) because of the trouble?

Have you had trouble at any time 

during the last 7 days?

Neck

 No  Yes  No  Yes  No  Yes

Shoulders

 No  Yes, right shoulder

 Yes, left shoulder

 Yes, both shoulders

 No  Yes  No  Yes

Elbows

 No  Yes, right elbow

 Yes, left elbow

 Yes, both elbows

 No  Yes  No  Yes

Wrist/Hands

 No  Yes, right wrist/hand

 Yes, left wrist/hand

 Yes, both wrists/hands

 No  Yes  No  Yes

Upper Back

 No  Yes  No  Yes  No  Yes

Lower Back (small of back)

 No  Yes  No  Yes  No  Yes

One or Both Hips/Thighs

 No  Yes  No  Yes  No  Yes

One or Both Knees

 No  Yes  No  Yes  No  Yes

One or Both Ankles/Feet

 No  Yes  No  Yes  No  Yes

(Based on the Nordic Questionnaire (Kourinka et al. 1987))
Risk Factor Reporting Card: Page 4

Risk Factor Reporting Card 

RISK FACTOR REPORT CARD Name: _____________________________

1. Work Area/Job Title: _____________________________________________________

2. Describe task: ___________________________________________________________

__________________________________________________________________________

3. Check all risk factors that apply 

Poor Posture 

Repetitive Work 

Vibrating Tools 

Static Posture 

WB Vibration

Forceful Gripping 

Heavy Lifting/Carrying 

Bouncing/Jarring 

Heavy Shoveling 

Forceful Push/Pull 

Other risk factors: _____________________________

5. Comments / Suggestions: __________________________

___________________________________________________

___________________________________________________

6. Plant / Mine Name: ________________________________

4. Place X on affected area 

Note: The Risk Factor Report Card can be printed on 3 × 5 or 4 × 6 index cards.
Manual Task Assessment: Page 5

Manual Task Assessment 

TASK: LOCATION: DATE:

ASSESSED BY: 

IN CONSULTATION WITH:

COMMENTS

(Reason Assessed; Tools, Equipment, Materials, Processes involved, etc.)

Manual task: any activity requiring the worker to grasp, manipulate, strike, throw, carry, move, hold or restrain an object, load or body part.
Manual Task Assessment: Page 6

Assess the degree of exposure to each primary risk factor for each body region using the table. Determine whether any of the 

additional risk factors listed are present. For the purposes of priority setting, a risk ranking may be determined using the numeric 

ratings in the table.

Green 

Score: 1 

Yellow 

Score: 2 

Orange 

Score: 4 

Red 

Score: 8 

Exertion Low force and speed Moderate forces or speed, but 

well within capability

High force or speed, but not 

close to maximal 

Forces or speeds close to the 

person’s maximum 

Duration Performed infrequently 

for short periods

Performed regularly, but with 

many breaks or changes of task

Performed frequently, without 

many breaks or changes of task

Performed continuously for 

majority of shift

Repetition Dynamic and varied 

patterns of movement

Little or no movement, or 

repeated similar movements 

Repeated identical movements 

□ Hot or Cold Environment

□ High Stress Environment

□ High Time Pressure

□ Lack of Control Over Work

□ Cognitive Over/Under Load

Lack of Opportunities for

Social Interaction

Posture Comfortable postures, 

within a normal range 

about neutral 

Uncomfortable postures, but not 

involving postures at the 

extreme of the range of motion

Postures at the extreme of the 

range of motion

Vibration No hand-arm or wholebody vibration

Moderate amplitude hand-arm 

vibration or whole-body vibration

High amplitude hand-arm 

vibration or whole-body vibration

□

Determine the body region(s) that may be at risk of injury. (Alternately, assess the task for each of the following regions: lower limbs; 

lower back; neck/shoulders and upper back; elbows, wrists and hands). 

Body Region Exertion Duration Repetition Posture Vibration Total Risk Score*

Neck, Shoulders and Upper Back

Elbows, Wrists and Hands

Low Back

Legs, Knees and Feet

*: Total Risk Score = Exertion Score + Duration Score + Repetition Score + Posture Score + Vibration Score

*: 5 - 10 = Low Risk 11 - 15 = Medium Risk 16 - 24 = High Risk

Engineering Controls Administrative Controls Personal Protective Equipment
Ergonomic Task Improvement Form: Page 7

Ergonomic Task Improvement Form 

<Insert Task Image>

Task: ____

MINE: ____

_________________________________________________________________________________________

______________________________________ DEPARTMENT: _____________________________________

TASK DESCRIPTION and RISK FACTOR EXPOSURES: _________________________________

___________________________________________________________________________

EQUIPMENT/TOOLS USED IN TASK: _____________________________________________

FREQUENCY OF TASK: _____________ NUMBER OF WORKERS AFFECTED: ______________

ROOT CAUSES OF RISK FACTORS: _______________________________________________

EMPLOYEE CONCERNS: ________________________________________________________

B 

E 

F 

O

R 

E 

Body Region Exertion* Duration* Repetition* Posture* Vibration* Total Risk Score#

Upper Body 

Neck, Shoulders and Upper Back

Upper Limbs

Elbows, Wrists and Hands

Low Back

Lower Limbs

Legs, Knees and Feet

OBJECTIVE OF CONTROL MEASURE: __

<Insert Task Image>

__________________________________________________________________

TASK DESCRIPTION and RISK FACTOR EXPOSURES: _________________________________

___________________________________________________________________________

EQUIPMENT/TOOLS USED IN TASK: _____________________________________________

FREQUENCY OF TASK: _____________ NUMBER OF WORKERS AFFECTED: ______________

ROOT CAUSES OF RISK FACTORS: _______________________________________________

EMPLOYEE CONCERNS: ________________________________________________________

Body Region Exertion* Duration* Repetition* Posture* Vibration* Total Risk Score#

Upper Body 

Neck, Shoulders and Upper Back

Upper Limbs

Elbows, Wrists and Hands

Low Back

Lower Limbs

Legs, Knees and Feet

#

:5 - 10 = Low Risk 11 - 15 = Medium Risk 16 - 24 = High Risk

OBJECTIVE OF CONTROL MEASURE: ____________________________________________________________________

*: Determine numeric rating based on table on following page or table shown in the Manual Task Assessment
Ergonomic Task Improvement Form: Page 8

Assess the degree of exposure to each primary risk factor for each body region using the following table. For the purposes of 

priority setting, a risk ranking may be determined using the numeric ratings in the table.

Green

Score: 1

Yellow

Score: 2

Orange

Score: 4

Red

Score: 8

Exertion Low force and speed Moderate forces or speed, but 

well within capability

High force or speed, but not 

close to maximal 

Forces or speeds close to the 

person’s maximum 

Duration Performed infrequently for 

short periods

Performed regularly, but with 

many breaks or changes of task

Performed frequently, without 

many breaks or changes of task

Performed continuously for 

majority of shift

Repetition Dynamic and varied patterns 

of movement

Little or no movement, or 

repeated similar movements 

Repeated identical movements 

Posture Comfortable postures, within 

a normal range about neutral 

Uncomfortable postures, but not 

involving postures at the 

extreme of the range of motion

Postures at the extreme of the 

range of motion

Vibration No hand-arm or whole-body 

vibration

Moderate amplitude hand-arm 

vibration or whole-body vibration

High amplitude hand-arm 

vibration or whole-body vibration

Total Risk Score = Exertion Score + Duration Score + Repetition Score + Posture Score + Vibration Score
References: Page 9

References

Kuorinka I, Jonsson B, Kilbom A, Vinterberg H, Biering-Sørensen, F, Andersson, G, Jørgensen, K [1987]. 

Standardised Nordic questionnaires for the analysis of musculoskeletal symptoms. Applied Ergonomics, 18(3), 

233–237.

NIOSH [2009]. Ergonomics processes: implementation guide and tools for the mining industry. By TormaKrajewski J, Steiner LJ, Burgess-Limerick R. Pittsburgh, PA: U.S. Department of Health and Human Services,

Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS 

(NIOSH) Publication No. 2009-107 (IC 9509).
Promoting productive workplaces through safety and health research