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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