.". Workplace Safety And Health ,WSH Safety Resources Blog: Indoor Air Quality Guidelines -Appendix C

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Indoor Air Quality Guidelines -Appendix C

SAMPLE CONFIDENTIAL QUESTIONNAIRE FOR BUILDING OCCUPANTS

To the occupant: This short questionnaire has been given to you to help determine the existence of health problems, if any, that may be related to the office environment. Your answers will remain confidential. Please complete the form as accurately as possible before returning to us. Thank you

 1 Demographic information

 1.1 Sex: Male / Female

1.2 Age:

1.3 Marital status: Single / Married

1.4 Ethnic group: Chinese / Malay / Indian / Other

2 Environmental conditions

2.1 Type of workstation: Enclosed room / Open concept

2.2 No. of people who share your workstation:

2.3 How is your area air-conditioned? Central unit / Local unit

2.4 How is your workstation lighted? Fluorescent lighting / Non-fluorescent lighting

2.5 Please indicate if you work with or near the following equipment:

Typewriter - Everyday / 2-3 times weekly / Never

Video display unit - Everyday / 2-3 times weekly / Never

Photocopier - Everyday / 2-3 times weekly / Never

Fax machine - Everyday / 2-3 times weekly / Never 2.6

Please rate the following conditions at your workstation:

Noise - Too much / Just right / Too little

Humidity - Too much / Just right / Too little

Lighting - Too much / Just right / Too little

Air movement - Too much / Just right / Too little

Temperature - Too hot / Just right / Too cold

2.7 Do you have to put on extra clothing for comfort?

Regularly / Sometimes / Never

2.8 Does the office air have an unpleasant odour?

Regularly / Sometimes / Never

2.9 Does the office air feel stuffy? Regularly / Sometimes / Never

3 Nature of occupation

3.1 No. of hours spent per day at your main workstation:

3.2 Please rate how you find the stress in your working conditions:

Physical stress experience - Low / Moderate / High

Mental stress experience - Low / Moderate / High

Climate of cooperation at work - Low / Moderate / High

3.3 What is your job category?

Managerial / Professional / Secretarial / Clerical / Other (if Other, specify):

4 Health complaints

4.1 Please indicate your experience of the following symptoms at work during the past one month:

Headache - Daily / 2-3 times weekly

 Less Lethargy - Daily / 2-3 times weekly

Less Drowsiness - Daily / 2-3 times weekly

Less Dizziness - Daily / 2-3 times weekly

Less Nausea/vomiting - Daily / 2-3 times weekly

Less Shortness of breath - Daily / 2-3 times weekly

Less Stuffy nose - Daily / 2-3 times weekly

Less Dry throat - Daily / 2-3 times weekly

Less Skin rash/itchiness - Daily / 2-3 times weekly

Less Eye irritation - Daily / 2-3 times weekly

4.2 No. of days in the past one month that you had to take off work because of these complaints:

4.3 When do these complaints occur? Mornings / Afternoons / No noticeable trend

4.4 When do you experience relief from these complaints? After I leave my workstation / After I leave the building / Never

4.5 Please indicate if you have any of these medical conditions: Asthma?

Yes, on medication / Yes, not on medication /

No Allergy? Yes, on medication / Yes, not on medication /

 No Sinus? Yes, on medication / Yes, not on medication /

No Migraine? Yes, on medication / Yes, not on medication /

4.6 If female, are you currently pregnant? Yes / No / Not sure

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