Ergonomics Symptoms Survey

Instructions:

For these questions, think about the last 7 days. Then, please rate how much and how frequently you may have experienced musculoskeletal discomfort.*

       *musculoskeletal discomfort means burning, numbness, or tingling in your muscles, joints, ligaments, tendons,or bones.
First Name:
Last Name:
Virginia Tech Email:
Phone#:
Department:
Supervisor:

Discomfort where?

How much?

How frequently?
  None Mild Moderate Severe Never Occasionally Frequently Always
EYES
SHOULDERS
ARMS
HANDS
BACK
LEGS

Discomfort where?

Which side?
Left Right Both Neither
SHOULDER(S)
BACK
ARM(S)
HAND(S)
LEG(S)

General questions:

 No problems Yes, but not this month Yes, this month
Have any of the above discomforts interfered with your daily activities?
Have any of the above discomforts caused you to miss work?
Have any of the above discomforts awakened you from sleep?
Have you seen a health care professional about any of the discomforts noted above?
How many years have you worked in your current job?
Less than 1 year   1 - 2 years   2 - 3 years   4 or more years  
Please share your top three (3) concerns about your current physical workstation and/or equipment that you use in the office or lab.
Are you concerned about developing musculoskeletal problems from your job? Yes No