EMPLOYEE MSD SYMPTOMS SURVEY

Please answer all questions truthfully and to the best of your ability.

1. Date: _____ / _____ / _____ 2. Name: ______________________________________
2. Job Title:______________________________________________________________
3. Department: _____________________ 5. Shift:_______________________________
4. Describe the type of work you perform in this job and the amount of time each day spent on these activities.

Task                                                                                  Time __________________________________________________      _______________________________________ __________________________________________________    […]