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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:
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
Do you think changes should be made to reduce the risk of musculoskeletal problems from your job in the next 6 months?
Yes
No
Do you think changes should be made in the next month or two?
Yes
No
Are you doing or have you done anything to reduce the risk?
Yes
No
If more than six months ago, do you intend to do anything more?
Yes
No
