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Surveys
2014
November
I
Introductory Survey
Introductory Survey
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Questions marked with an
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are required
Exit Survey
*
Participant #: (last 4 digits of office phone)
*
What is your age range?
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18-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70+
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Todays date:
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Jan
Feb
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Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
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2024
*
Department:
*
Job Title:
*
What are your job tasks? Check all that apply
Keyboarding
Phone calls
Filing
Teaching
Composing text at computer
Data entry
Email
Other
*
How long do you work at any time before taking a break?
*
Describe what you do during your breaks:
*
Do you have any discomforts such as (strains, aches or pains) caused by work?
Yes
No
*
Is there ergonomic information related to your work station at work you would like to know about?
*
Is there ergonomic information related to your activities outside of work you would like to know about?
*
When did you first notice your discomfort?
*
What kind of treatment did you receive?
*
Have you had to seek medical attention because of your discomfort?
Yes, but no relief
Yes, Some relief
No need
Not yet not bad enough
Not yet due to finances
Other
*
Is there ergonomic information related to your work station at work you would like to know about?
*
Is there ergonomic information related to your activities outside of work you would like to know about?
*
On a pain scale of 0 being no pain and 5 being extreme pain) how would you rate your discomfort right now? (Aches, pains, discomforts, strains)
0 No Pain
1 Minimal Pain
2 Mild Pain
3 Moderate Pain
4 Severe Pain
5 Extreme Pain
*
What word(s) would you use to describe the pain/discomfort?
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