Please take a moment to describe your daily job duties:
How Many Hours do You Work Per Day?
How Many Days Per Week?
(If you are a union member, please complete the section below.)
(Please list any co-workers who should be notified in case of an injury)
(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:
(Mark an X along the line)
(Circle the number that corresponds to your rating)
7a. If NO, why not?
7b. If YES, where did you receive treatment?
Times in past year
7c. Did treatment help?