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
Ergonomics Discomfort Survey_2
Right Side
Revision Date: 01-Jun-15
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