Pain Evaluation Form

Details

Employee Details

Company *

Full Name *

Staff ID

Department

Designation

Contact No

Gender *

Male

Female

Section 1: Office Ergonomic Evaluation

Seksyen 1: Penilaian Ergonomik Pejabat

#	Question / Soalan
A. Work Surface/Permukaan Kerja		Yes	No	N/A
1	Are you able to adjust the height of your work surface? Adakah anda dapat melaraskan ketinggian permukaan kerja anda?
2	Do you have sufficient knee clearance and leg room? Adakah anda mempunyai kelegaan lutut dan ruang kaki yang mencukupi?
3	If Visual Display Unit (screen display) work is your main task, is the monitor positioned directly in front of you? Jika kerja Unit Paparan Visual (paparan skrin) adalah tugas utama anda, adakah monitor diletakkan terus di hadapan anda?
4	Is your work surface large enough to perform the required tasks and to hold all the equipment? Adakah permukaan kerja anda cukup besar untuk melaksanakan tugas yang diperlukan dan untuk menampung semua peralatan?
5	Are frequently accessed items (e.g. phone, files, etc.) within easy reach? Adakah item yang kerap diakses (cth. telefon, fail, dll.) mudah dicapai?
6	Are power sockets easily accessible? Adakah soket kuasa mudah diakses?
B. Chairs/Kerusi		Yes	No	N/A
7	Is your chair height adjustable? Adakah anda dapat melaraskan ketinggian kerusi anda?
8	Is your chair backrest adjustable (backward, forward, vertically)? Adakah anda dapat melaraskan sandaran kerusi anda (ke belakang, ke hadapan, menegak)?
9	Is your seat pan size suitable for you? Adakah saiz tempat duduk anda sesuai untuk anda?
10	Does your seat pan have a rounded “waterfall” edge? Adakah tempat duduk anda mempunyai tepi "air terjun" yang bulat?
11	Is your armrest height adjustable? Adakah anda dapat melaraskan tempat letak tangan anda?
12	Does your chair have 5 castors? Adakah kerusi anda mempunyai 5 kastor?
13	Is your chair able to revolve? Adakah kerusi anda boleh berputar?
14	Are all the chair adjustments easy to locate and operate? Adakah semua pelarasan kerusi mudah dicari dan dikendalikan?
C. Monitor/Monitor		Yes	No	N/A
15	Is your monitor at least 14” in size? Adakah monitor anda bersaiz sekurang-kurangnya 14"?
16	Is the top of your monitor screen at or slightly below your eye level? Adakah bahagian atas skrin monitor anda berada di bawah atau sedikit di bawah paras mata anda?
17	Is your monitor located at about an arm’s length in front of you? Adakah monitor anda terletak kira-kira satu lengan di hadapan anda?
18	If you use a document holder, can you position it at the same height and same distance as the screen? Adakah anda menggunakan pemegang dokumen? Jika YA, bolehkah anda meletakkannya pada ketinggian dan jarak yang sama dengan skrin?
19	Can your monitor be tilted forward and backward and rotated? Bolehkah monitor anda dicondongkan ke hadapan dan ke belakang serta diputar?
20	Is your monitor free from any noticeable flicker? Adakah monitor anda bebas daripada sebarang kelipan yang ketara?
D. Input Devices/Peranti Input		Yes	No	N/A
21	Is your mouse located beside or close to the keyboard? Adakah tetikus anda terletak di sebelah atau dekat dengan papan kekunci?
22	Is your mouse at the same height as your keyboard? Adakah tetikus anda pada ketinggian yang sama dengan papan kekunci anda?
23	Do you keep your wrists straight while using the input devices? Adakah anda mengekalkan pergelangan tangan anda lurus semasa menggunakan peranti input?
E. Work Posture/Postur Kerja		Yes	No	N/A
24	Do you sit in a slightly reclining and relaxed posture with the back supported and the feet resting comfortably on the floor or a footrest? Adakah anda duduk dalam postur yang sedikit berbaring dan santai dengan punggung disokong dan kaki berehat dengan selesa di atas lantai atau tempat letak kaki?
25	Are you able to avoid poor working posture, such as neck bending or twisting or unsupported back? Adakah anda dapat mengelakkan postur kerja yang lemah, seperti leher membongkok atau berpusing atau belakang tidak disokong?
F. Manual Handling/Pengendalian Manual		Yes	No	N/A
26	Do you have to frequently reach above the shoulder or below the knee level? Adakah anda kerap perlu menjangkau di atas bahu atau di bawah paras lutut?
27	Do you use trolleys or carts to move heavy objects (more than 3 kg) instead of carrying them? Adakah anda menggunakan troli untuk mengalihkan objek berat (lebih daripada 3 kg) dan bukannya mengangkatnya?
G. Lighting/Pencahayaan		Yes	No	N/A
28	Do you think you receive enough lighting at your workstation? Adakah anda fikir anda menerima pencahayaan yang mencukupi di stesen kerja anda?
29	Are you able to adjust the lighting at your workstation? Adakah anda mengalami keletihan mata akibat silau atau pencahayaan malap?
30	Do you experience eyestrain from glare or low lighting? Adakah anda mengalami keletihan mata akibat silau atau pencahayaan malap?
H. Ambient Noise/Bunyi Ambien		Yes	No	N/A
31	Do you consider your work environment to be noisy? Adakah anda menganggap persekitaran kerja anda bising?
32	Are there any forms of noise isolation or enclosure to reduce noise? Adakah terdapat sebarang bentuk pengasingan bunyi atau kepungan untuk mengurangkan bunyi?
I. Temperature & Humidity/Suhu & Kelembapan		Yes	No	N/A
33	Do you think that it is too cold or too hot at your workstation? Adakah anda berpendapat ia terlalu sejuk atau terlalu panas di stesen kerja anda?
34	Are you able to adjust the temperature at your workstation? Adakah anda boleh melaraskan suhu di stesen kerja anda?
35	Do you think it is too humid or too dry at your workstation? Adakah anda berpendapat kelembapan terlalu lembap atau terlalu kering di stesen kerja anda?
J. Ventilation/Pengudaraan		Yes	No	N/A
36	Are you troubled by odour, smoke, dust or excessive air flow at your workstation? Adakah anda terganggu dengan bau, asap, habuk atau aliran udara yang berlebihan di stesen kerja anda?
37	Do you experience drowsiness or fatigue at your workstation? Adakah anda mengalami rasa mengantuk atau keletihan di stesen kerja anda?

Section 2: Body Part Evaluation

Seksyen 2: Penilaian Bahagian Badan

The diagram below shows the approximate position of the body parts referred to in the questionnaire. Please answer by marking the appropriate box.

Rajah di bawah menunjukkan kedudukan anggaran bahagian badan yang dirujuk dalam soal selidik. Sila jawab dengan menandakan kotak yang sesuai.

Body Part / Bahagian Badan	During the last work week, how often did you experience ache, pain or discomfort in the body part? Sepanjang minggu lepas, berapa kali anda mengalami rasa sakit atau ketidakselesaan dalam bahagian badan?					If you experienced ache, pain or discomfort, how uncomfortable was this? Jika anda mengalami sakit atau ketidakselesaan, betapa tidak selesa ia?			If you experienced ache, pain or discomfort, did this interfere with your ability to work? Jika anda mengalami rasa sakit atau rasa tidak selesa, adakah ini mengganggu keupayaan anda untuk bekerja?
	FREQUENCY/KEKERAPAN (F)					DISCOMFORT/KETIDAKSELESAAN (D)			INTERFERENCE/GANGGUAN (I)
	Never Tidak pernah	1-2 times last week 1-2 kali dalam seminggu	3-4 times last week 3-4 kali dalam seminggu	Once every day Sekali sehari	Several times every day Banyak kali sehari	Slightly uncomfortable Sedikit tidak selesa	Moderately uncomfortable Tidak selesa	Very uncomfortable Sangat tidak selesa	Not at all Langsung tidak mengganggu	Slightly interfered Mengganggu sedikit	Substantially interfered Sangat mengganggu
	1 Neck/Leher
	2 Shoulder (Right)/Bahu (Kanan)
Shoulder (Left)/Bahu (Kiri)
3 Upper Back/Bahagian Atas Belakang
4 Upper Arm (Right)/Lengan Atas (Kanan)
Upper Arm (Left)Lengan Atas (Kiri)
5 Lower Back/ Bahagian Bawah Belakang
6 Forearm (Right)/ Lengan Bawah (Kanan)
Forearm (Left)/Lengan Bawah (Kiri)
7 Wrist (Right)/ Pergelangan Tangan (Kanan)
Wrist (Left)/ Pergelangan Tangan (Kiri)
8 Hip or Buttocks / Pinggul atau Punggung
9 Thigh (Right)/ Peha (Kanan)
Thigh (Left)/ Peha (Kiri)
10 Knee (Right)/ Lutut (Kanan)
Knee (Left)/ Lutut (Kiri)
11 Lower Leg (Right)/ Betis (Kanan)
Lower Leg (Left)/ Betis (Kiri)
12 Foot (Right)/ Kaki (Kanan)
Foot (Left)/ Kaki (Kiri)

Section 3: Right Hand Evaluation

Seksyen 3: Penilaian Tangan Kanan

Right Hand Part / Bahagian Tangan Kanan	During the last work week, how often did you experience ache, pain or discomfort in the body part? Sepanjang minggu lepas, berapa kali anda mengalami rasa sakit atau ketidakselesaan dalam bahagian badan?					If you experienced ache, pain or discomfort, how uncomfortable was this? Jika anda mengalami sakit atau ketidakselesaan, betapa tidak selesa ia?			If you experienced ache, pain or discomfort, did this interfere with your ability to work? Jika anda mengalami rasa sakit atau rasa tidak selesa, adakah ini mengganggu keupayaan anda untuk bekerja?
	FREQUENCY/KEKERAPAN (F)					DISCOMFORT/KETIDAKSELESAAN (D)			INTERFERENCE/GANGGUAN (I)
	Never Tidak pernah	1-2 times last week 1-2 kali dalam seminggu	3-4 times last week 3-4 kali dalam seminggu	Once every day Sekali sehari	Several times every day Banyak kali sehari	Slightly uncomfortable Sedikit tidak selesa	Moderately uncomfortable Tidak selesa	Very uncomfortable Sangat tidak selesa	Not at all Langsung tidak mengganggu	Slightly interfered Mengganggu sedikit	Substantially interfered Sangat mengganggu
	Area A
	Area B
Area C
Area D
Area E
Area F

Section 4: Left Hand Evaluation

Seksyen 4: Penilaian Tangan Kiri

Left Hand Part / Bahagian Tangan Kiri	During the last work week, how often did you experience ache, pain or discomfort in the body part? Sepanjang minggu lepas, berapa kali anda mengalami rasa sakit atau ketidakselesaan dalam bahagian badan?					If you experienced ache, pain or discomfort, how uncomfortable was this? Jika anda mengalami sakit atau ketidakselesaan, betapa tidak selesa ia?			If you experienced ache, pain or discomfort, did this interfere with your ability to work? Jika anda mengalami rasa sakit atau rasa tidak selesa, adakah ini mengganggu keupayaan anda untuk bekerja?
	FREQUENCY/KEKERAPAN (F)					DISCOMFORT/KETIDAKSELESAAN (D)			INTERFERENCE/GANGGUAN (I)
	Never Tidak pernah	1-2 times last week 1-2 kali dalam seminggu	3-4 times last week 3-4 kali dalam seminggu	Once every day Sekali sehari	Several times every day Banyak kali sehari	Slightly uncomfortable Sedikit tidak selesa	Moderately uncomfortable Tidak selesa	Very uncomfortable Sangat tidak selesa	Not at all Langsung tidak mengganggu	Slightly interfered Mengganggu sedikit	Substantially interfered Sangat mengganggu
	Area A
	Area B
Area C
Area D
Area E
Area F