Construction Health Surveillance Questionnaire
Construction Health Surveillance Questionnaire: Please complete all sections to assist with your workplace health surveillance review.
Full Name
*
First Name
Last Name
Job Role/Title
*
Duration of Employment in Construction (years)
*
Are you currently experiencing any of the following symptoms? (Select all that apply)
*
Cough
Shortness of breath
Skin irritation
Hearing problems
Muscle or joint pain
None of the above
Other
Do you regularly use the required personal protective equipment (PPE) at work?
*
Always
Sometimes
Rarely
Never
Have you been exposed to any of the following at work in the last 12 months? (Select all that apply)
*
Dust (e.g., silica, wood)
Noise
Vibration
Chemicals
Manual handling
None of the above
Other
How would you rate your general health over the past month?
*
Very poor
1
2
3
4
Excellent
5
1 is Very poor, 5 is Excellent
Do you have any long-term health conditions that may affect your work?
*
Yes
No
Not sure
In the past year, have you had any work-related injuries or illnesses?
*
Yes
No
Please provide any additional information relevant to your health at work.
Submit
Should be Empty: