Ergonomics discomfort survey 2 fillable form

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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

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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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