Staff Feedback Survey

Download the survey for the printable version.

Department:

Work area:

Job Name:

Room no./Machine no./Location:

Questions:

1. What is the most physically difficult task you do?
2. How often do you perform this task? 
3. What is the second most physically difficult task you do?
4. How often do you perform this task?
5. Do any of your job tasks require you to:
   1. Repeat the same movements or actions more than a few times a minute for more than 30 minutes at a time? 
      If yes, list the three most 'repetitive' tasks.
   2. Lift, push, pull, or move heavy items?
      If yes, list the three heaviest items you lift, push, pull, or move.
6. Do any of your jobs require you to work in awkward postures (working with arms above the shoulder, bending/twisting at the waist, lifting while bending or twisting, bending wrists up/down frequently, reaching behind the body)?
   If yes, list the three most awkward or uncomfortable postures you must work in and the tasks where they are required.
7. Is the lighting in your work area suitable?
   If no, please indicate why not:
   1. too much light/too bright/glare/reflections
   2. not enough light/dull/shadows
   3. lights in the wrong place
   4. sunlight causes problems (some or all of the day)
8. is the temperature in the work area suitable?
   If no, please indicate why not:
   1. too cold (in winter or due to air conditioning)
   2. too warm (in summer or due to thermostat too high)
   3. drafts or another issue
9. is the noise level in the work area satisfactory?
   1. too noisy due to equipment/machines
   2. too noisy due to co-worker conversations/music 
10. Please check any of the following that are a concern or problem in your work area and provide some detail.
    1. poor hand tools 
    2. noise
    3. lighting
    4. temperature
    5. stress
    6. poor control design/layout
    7. poor display design/layout
    8. standing/walking
    9. lack of control over process
11. Please check any of the following that are a concern or problem in your work area and provide some detail.
    1. seating
    2. workstation adjustability
    3. working reaches
    4. repetitive motions
    5. heavy lifting
    6. awkward postures
    7. mental strain
    8. too much work variety
    9. too little work variety 
12. Do you ever feel any pain or discomfort while at work or when leaving at the end of your shift?
    If yes, please indicate the types of discomfort you feel. 
13. List 5 things you would like to see changed in the design, set-up or organization of your work.
14. Do you have any suggestions to fix or eliminate some of the concerns you have with your job or ideas to make the job better? If so, write them down on the back of this page or talk them over with your supervisor.

NOTE: Your ideas can be simple or complex. All ideas will be evaluated and discussed. It is very likely that you will be asked to participate in these discussions. Any decision regarding your suggestion will be made known to you and you will be advised as to why your idea or suggestion will or will not be implemented.