1762 Clifton Road, Suite 1200 Atlanta, Georgia 30322 (404) 727-5922 FAX: (404) 727-9778
ERGONOMICS DISCOMFORT SURVEY Please complete the Discomfort Survey based on your average workday. Fill in all of the information requested below. Please respond honestly and thoughtfully. Name:
Date:
Job Title:
Hrs. per week:
Department:
Months in current job:
Supervisor:
Right/Left Handed?
1. Describe your symptoms (if any) on the following diagram by writing the letters (N, T, A, B, S) on the affected area of the body. N=Numbness T=Tingling A=Aching B=Burning S=Stiffness
Left Side
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Right Side
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ERGONOMICS DISCOMFORT SURVEY 2.
Rate discomfort severity and frequency for each region in the following chart: AFFECTED AREA
SIDE
DISCOMFORT LEVEL
HOW OFTEN?
Left
None Moderate Severe Maximum
Rarely Occasionally Frequently Constantly
Right
None Moderate Severe Maximum
Rarely Occasionally Frequently Constantly
Left
None Moderate Severe Maximum
Rarely Occasionally Frequently Constantly
Right
None Moderate Severe Maximum
Rarely Occasionally Frequently Constantly
Left
None Moderate Severe Maximum
Rarely Occasionally Frequently Constantly
Right
None Moderate Severe Maximum
Rarely Occasionally Frequently Constantly
None Moderate Severe Maximum
Rarely Occasionally Frequently Constantly
Right
None Moderate Severe Maximum
Rarely Occasionally Frequently Constantly
Left
None Moderate Severe Maximum
Rarely Occasionally Frequently Constantly
Right
None Moderate Severe Maximum
Rarely Occasionally Frequently Constantly
Head/Neck/Eyes
Upper/Mid Back
Low Back/Pelvis
Left
Shoulder/Upper Arm
Elbow/Mid Arm
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ERGONOMICS DISCOMFORT SURVEY AFFECTED AREA
SIDE
DISCOMFORT LEVEL
HOW OFTEN?
Left
None Moderate Severe Maximum
Rarely Occasionally Frequently Constantly
Right
None Moderate Severe Maximum
Rarely Occasionally Frequently Constantly
Left
None Moderate Severe Maximum
Rarely Occasionally Frequently Constantly
Right
None Moderate Severe Maximum
Rarely Occasionally Frequently Constantly
Left
None Moderate Severe Maximum
Rarely Occasionally Frequently Constantly
Right
None Moderate Severe Maximum
Rarely Occasionally Frequently Constantly
Left
None Moderate Severe Maximum
Rarely Occasionally Frequently Constantly
Right
None Moderate Severe Maximum
Rarely Occasionally Frequently Constantly
Left
None Moderate Severe Maximum
Rarely Occasionally Frequently Constantly
Right
None Moderate Severe Maximum
Rarely Occasionally Frequently Constantly
Forearm/Wrist
Hand
Upper Leg/Hip
Mid Leg/Knee
Lower Leg/Foot
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ERGONOMICS DISCOMFORT SURVEY 3. When did you first notice your discomfort? Number of
months -or-
years ago
4. How long does each episode last?
Choose item.one of the following: Please an select 5. Have you missed any time from work because of your discomfort? Yes
No
6. Have you had to seek medical attention because of your discomfort? Yes
No
7. Have you changed jobs or modified duties because of your discomfort? Yes
No
8. What do you think caused the discomfort?
9. Are there any changes or recommendations that you think could be made to the work environment to reduce the discomfort?
Send a completed copy of this discomfort survey to the EHSO Safety/IH Group at indhyg@emory.edu. Complete a PeopleSoft Incident Report, as soon as possible.
Contact EHSO at 404-727-5922 or indhyg@emory.edu if you need further assistance.
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