Ergonomic Comfort Survey
Email address *
Name: *
Date: *
MM
/
DD
/
YYYY
Occupation: *
Hours worked per week: *
What is your most common shift =? *
Time working in present position (years and months) *
Total time working in your occupation (years and months) *
Have you had any discomfort during the last year? (If not, stop here.) *
Please check the location(s) of discomfort during the past year.
Please check the location(s) of discomfort currently.
Please describe your discomfort in the area(s) checked.
Please rate your discomfort in severity.
Very Mild
Intolerable
When did you notice the discomfort?
When was the most recent occurrence of your discomfort?
Is discomfort intermittent or constant?
How many separate episodes of discomfort in the last year?
What do you think caused your discomfort?
Have you had medical treatment for your discomfort?
If not, do you plan to have medical treatment for your discomfort?
Has your condition affected how you perform your job?
Has experienced loss in range of motion, weakness, or numbness?
Do any of your hobbies or sports cause the same discomfort?
If yes, which ones:
Please comment on what you think would ease or eliminate your discomfort at work.
Thanks for completing our comfort survey. After completing the survey, please email us at wearelavoro@gmail.com to alert us of this.
(CBES Ergonomic Comfort Survey
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