Worker Discomfort Survey

For printable version users can fill out, download this resource. 

Completed by:

Date:

Job name:

Shift:

Department:

Time on job:

Please list other jobs you have done in the last year (for more than two weeks).
Note: If more than two jobs, only include those you worked on the most

Questions:

1. Have you had pain or discomfort during the last year that you feel is job-related? (Yes/No)
   If no, stop here. 

2. If yes, please rate the level of discomfort over the last month by checking off the appropriate box using the scale of 0 to 10, with 0 being no discomfort and 10 being the worst discomfort ever.

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3. When did you first notice your discomfort? (indicate month, year)
4. What do you think caused the discomfort?
5. Please comment on what you think would help to reduce your level of discomfort.
6. Do you consider your discomfort to be a problem? (Yes/No)
7. Have you received medical treatment (from a doctor, chiropractor, physiotherapist, massage therapist or other health care practitioner) for your discomfort? (Yes/No)
8. Have you taken time off work because of your discomfort (vacation, sick days, lost time claim, medical aid)? (Yes/No)

Content sourced from the MSD Prevention Guideline for Ontario, Part 3B: MSD Prevention Toolbox (2007)