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About IFWAA

Get Your Free Physical Evaluation Today

OCCUPATIONAL HEALTH AWARENESS SURVEY

1. federal employee information

Marital Status

Have you ever had an injury at work?

Do you have physical discomfort doing work duties?

Do you take pain relievers regularly?

Gender:

2. msd common risk factors

Please take a moment to describe your daily job duties:

How Many Hours do You Work Per Day?

How Many Days Per Week?

do your job duties require: (check all that apply.)

2a. Common Symptoms of Musculoskeletal Disorder (MSD’s)

3. EMPLOYEE UNION INFORMATION

Union Member?

(If you are a union member, please complete the section below.)

4. EMPLOYEE INJURY/CO-WORKER CONTACT INFORMATION

(Please list any co-workers who should be notified in case of an injury)

5. INJURED FEDERAL EMPLOYEE STATEMENT

(complete this section only if you have symptoms or working in discomfort)

Please give a brief statement describing how you believe your daily work duties may be causing your symptoms or discomfort:

6. Thank you for taking the survey.

Would you like to arrange to see a physician at no cost?

Best time to call:

Preferred Method of Contact :

7. AUTHORIZATION

Have you had any pain or discomfort during the last (2) years?

Circle or highlight the part of the body where you are experiencing pain or discomfort.

[Front]

body

[Back]

body

* This page can be copied and completed for each body area where the discomfort/pain is felt.*

Check body area of discomfort/pain:

1. When did you first notice the problem?

2. How long does each episode last?

(Mark an X along the line)

3. How many separate episodes have you had in the last year?

4. What do you think caused the problem?

5. Have you had this problem in the last 7 days?

6. How would you rate the severity of this problem?

(Circle the number that corresponds to your rating)

Now:

When it’s the worst:

7. Have you had medical treatment for this problem?

  • 7a. If NO, why not?

  • 7b. If YES, where did you receive treatment?

  • Times in past year

    Times in past year

    Times in past year

  • 7c. Did treatment help?

8. How much time have you lost in the last year because of this problem?

9. How many days in the last year were you on restricted/light duty because of this problem?

10. Please comment on what you think would improve your symptoms.