Optim Ergonomics : Survey

Occupational Health & Safety
Ergonomic Survey for employees

Printable version of this survey is available here

Name*
Address
E-mail*
DOB (YYYY/MM/DD)
Tel (Work) *
(Home)
(Mobile)
(Fax)
Sex
Company
Dept or Division
Work place?
Would you like a workstation assessment as soon as possible?

Rating Scale	1 Noticeable	3 Very Uncomfortable
0 No Problem	2 Un-comfortable	4 Major Concern

1. Do you experience any pain or discomfort when working ?

2. Are you currently having treatment for any pain or discomfort or have you had treatment recently?

3. Do you have sore shoulders?

4. Do you have a sore neck?

5. Do you have sore hands or fingers?

6. Do you have sore wrists?

7. Do you have sore arms?

8. Do you have upper back pain?

9. Do you have pain between your shoulder blades?

10. Do you have pain in middle of your back?

11. Do you have lower back pain?

12. Do you have any tingling feeling in any part of your body?

13. Do you have any numb feeling in any part of your body ?

14. Do you have dry and/or watery eyes ?

15. Do you find it hard to sit upright?

16. Do you have any acute pain anywhere in your body?

17. Are there any other identifiable Occupational Health and Safety hazards or concerns in your work area?

lightning
temperature
furniture
ventilation
noise
other please specify