Perceived Exertion Survey
Date:
Please rate the physical demands required to perform each job/task.
| Job Name: | Task 1 | Task 2 | Task 3 | Task 4 |
|---|---|---|---|---|
| Department: | Write name of task in box below | |||
| Location: | ||||
| Have you worked at this job and performed this task? | Yes / No | Yes / No | Yes / No | Yes / No |
| What is your overall rating of exertion or effort at this Job? (ScaleA) | ||||
| Foreach task, how hard or tiring is the workon your shoulders? (Scale A) | ||||
| For each task, how hard or tiring is the work on your neck? (Scale A) | ||||
| For each task, how hard or tiring is the work on your back? (Scale A) | ||||
| For each task, how hard or tiring is the work on your legs and feet? (Scale A) | ||||
| For each task, how hard or tiring is the work on your fingers, wrist and forearm? (Scale A) | ||||
| For each task, how hard must you grip parts or tools with your hand and fingers? (Scale A) | ||||
| For each task, how would you rate the movements of your wrist, hand and fingers? (Scale B) | ||||
| Total | ||||
Scale A: Use to indicate how hard or tiring your job is: 0 - Nothing at all 0.5 - Extremely weak effort 1 - Very weak effort 2 - Weak effort 3 - Moderate effort 5 - Strong effort 7 - Very strong effort 10 - Extremely strong effort | Scale B: Use for rating wrist, hand and finger activity 0 - Hands idle most of the time, no regular exertions 2- Consistent, obvious, long pauses; OR very slow motions 4 -Slow steady motions/exertions; frequent brief pauses 6 - Steady motions/exertions; no regular pauses 8 - Rapid steady motions/exertions; no regular pauses 10 - Rapid continuous motions/exertions; difficulty keeping up | |||
Modified version of tool thatappear in Research at Work: Ergonomics Program Implementation Blueprint. Richard Wells, Robert Norman Mardon Frazer and Andrew Laing. University of Waterloo. Used with Permission.
Modified from Part 3B: MSD Prevention Toolbox - Beyond the Basics Developed by Occupational Health and Safety Council of Ontario (OHSCO)