Workplace Questionnaire

This self-assessment questionnaire is designed for the manager or employee to determine if the building they are working in, is a toxic environment or suffering from the
phenomena known as “SBS” – Sick Building Syndrome. The World Health Organisation (WHO) has estimated that over 30% of office buildings suffer from SBS. This study did
not include private homes. Use this self-assessment tool as a guide to gauge where the health of your work environment sits and use it to form an action plan to change the
health of your work place and the people who work in it. If you answer “Yes” or “Often” to six or more questions, your work space will need an environmental intervention
and changes to be made. Your health and the health of your colleagues, and employees are at risk every day you don’t fix a toxic building. If you have determined that your
building suffers from SBS please arrange a consultation with us at Riverina Building Certifiers to help get your work place and occupants back to state of wellness and
happiness.
Year of birth
Sex
Do you smoke?
Occupation
How long have you been at your present place of work?

Q1. Have you been bothered during the last three months by any or all of the following factors at your work space?
Y (every week) Y (sometimes/occasionally) No (never)
1. Drought
2. Too high room temperature
3. Varying room temperature
4. Too low room temperature
5. Stuffy “bad” air
6. Dry air
7. Unpleasant smell
8. Static electricity, often causing shocks
9. Noise
10. Light that is dim or causes glare and/or reflections
 Y (every week) Y (sometimes/occasionally) No (never)

11. Dust and dirt

12. Feeling lethargic or fatigued?
13. Feeling down or depressed?
14. Does the room feel humidity?

Work Conditions Yes (often) Y (sometimes) No (seldom) No (never)

15. Do you regard your work as interesting and stimulating?
16. Do you have too much to do?
17. DO you have any chance to influence your working conditions?
18. Do you fellow-workers help you with problems you may have in your work?
19. Do you feel valued as an employee?
20. Do you feel like there is a team environment in your work place?
21. Do you enjoy coming to work and the type of work you do?
22. Do you feel comfortable in your work place?
23. Past/Present diseases & symptoms
24. Have you ever had asthmatic problems or trouble breathing?
25. Have you ever had hay fever?
26. Have you had or have eczema?
27. Do you have any other respiratory issues? Please describe______________________________________________________

28. Do you have any other physical symptoms? ______________________________________________________________

Additional notes and comments: