IEP Comfort Suvey

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Name:

• Select date

  Date

• Job Title

• Portfolio

• Supervisor

• Height

• Have you ever had any pain or discomfort during the last year that you believe is related to your work?

  Yes

  No

  N/A

• Dominant Hand:

  Left

  Right

  Either

• Gender:

  Male

  Female

• How long have you work in your current position?

  < 3 M

  < 1 Y

  < 5 Y

  < 10 Y

  > 10 Y

• How often are you physically exhausted due to work?

  Never

  Occ

  Often

  Always

• For each discomfort indicate what you think is causing or caused it

Discomfort

• Body Part

• Previous injury ?

  Yes

  No

  N/A

• Possible Cause

• What aggravated the problem?

• Are lighting or noise a source of discomfort during work?

  Yes

  No

  N/A

• Do you have any suggestions to improve your situation?

Experiencing Pain?

• Neck

  Select Left Right N/A

  • Left
  • Right
  • N/A

• How Often?

  Never

  Occ

  Often

  Always

• Select from range

• Elbow

  Select Left Right N/A

  • Left
  • Right
  • N/A

• How Often?

  Never

  Occ

  Often

  Always

• Select from range

• Forearms

  Select Left Right N/A

  • Left
  • Right
  • N/A

• How Often?

  Never

  Occ

  Often

  Always

• Select from range

• Wrist/Hands

  Select Left Right N/A

  • Left
  • Right
  • N/A

• How Often?

  Never

  Occ

  Often

  Always

• Select from range

• Thighs

  Select Left Right N/A

  • Left
  • Right
  • N/A

• How Often?

  Never

  Occ

  Often

  Always

• Select from range

• Ankles/Feet

  Select Left Right N/A

  • Left
  • Right
  • N/A

• How Often?

  Never

  Occ

  Often

  Always

• Select from range

• Shoulders

  Select Left Right N/A

  • Left
  • Right
  • N/A

• How Often?

  Never

  Occ

  Often

  Always

• Select from range

• Upper Back

  Select Left Right N/A

  • Left
  • Right
  • N/A

• How Often?

  Never

  Occ

  Often

  Always

• Select from range

• Lower Back

  Select Left Right N/A

  • Left
  • Right
  • N/A

• How Often?

  Never

  Occ

  Often

  Always

• Select from range

• Hips

  Select Left Right N/A

  • Left
  • Right
  • N/A

• How Often?

  Never

  Occ

  Often

  Always

• Select from range

• Knees

  Select Left Right N/A

  • Left
  • Right
  • N/A

• How Often?

  Never

  Occ

  Often

  Always

• Select from range

• Lower Legs

  Select Left Right N/A

  • Left
  • Right
  • N/A

• How Often?

  Never

  Occ

  Often

  Always

• Select from range

• Other

  Select Left Right N/A

  • Left
  • Right
  • N/A

• How Often?

  Never

  Occ

  Often

  Always

• Select from range