Questionnaire of Hazardous Work for Temporary Employee
First, please input your e-mail address below.
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Email *
Affiliated Dept. *
ID No.
If you have the Kyoto university employee ID, please input  8 digits to the left of your【Employee ID】◆ NOT your SPS-ID、KING-ID◆
First name *
in kana
Last name *
in kana
First name *
in kanji/alphabet
Last name *
in kanji/alphabet
Sex *
Date of birth *
YYYY/MM/DD
MM
/
DD
/
YYYY
Work place, Employee type
Work place *
Select where you do most of your work.
Employee type *
Contact information *
cell phone number or extension number
Hazardous work and time
Select up to 3 in descending order. Only select work you are exposed to for more than 100 days/year.
Main Work *
Give details for ( * ) starred items in the “Special Notes” section below.
Time exposed to “Main Work” (days per year)
Work 2
Give details for ( * ) starred items in the “Special Notes” section below.
Time exposed to “Work 2” (days per year)
Work 3
Give details for ( * ) starred items in the “Special Notes” section below.
Time exposed to “Work 3” (days per year)
Does your work involve handling HBV or  B virus(monkey)? *
Time of work with HBV (days per year)
Time of work with B virus(monkey)　(days per year)
Present & Past illnesses *
Check none when none below applies.
Symptoms
Give details for ( * ) starred items in the “Special Notes” section below. Please leave blank or select “None” for symptoms you do not have.
None
In treatment
Under observation
In the past
Hypertension
Myocardial infarction / Angina pectoris
Arrhythmia
Other heart disease *
Pulmonary tuberculosis
Other lung disease (including Asthma) *
Stomach / Duodenal ulcer
Liver disease
Gall stone
Gallbladder polyp
Other gastrointestinal disease *
Kidney / Ureteral stone
Other kidney disease *
Diabetes / Impaired glucose tolerance
Dyslipidemia / Hyperlipidemia
Hyperuricemia / gout
Anemia
Other blood disease *
Eye disease *
Ear disease *
Nose disease *
Skin disease *
Bone / Joint disease *
Gynecological disease *
Mental health issues *
Other disease *
Clear selection
Do you have symptoms related to work experienced in the last 1~2 months? *
Check “No” or enter information on your symptoms below.
Symptoms
Give details for ( * ) starred items in the “Special Notes” section below. Please leave blank or select “No” for symptoms you do not have.
No
Yes
Extreme shortness of breath on exertion
Swelling to the point skin dents when pressed
Cough and/or phlegm persisting for two weeks or longer
Bloody phlegm
Severe nausea
Abdominal pain persisting for two weeks or longer
Unintended weight loss
Unusual fatigue persisting for two weeks or longer
Headaches and heavy-headedness persisting for two weeks or longer
Shoulder aches for two weeks or longer
Paralysis, numbness, trembling of hands lasting over 2 weeks
Paralysis, numbness, trembling of legs/feet lasting over 2 weeks
Low back pain for two weeks or longer
Dizziness ( spinning , floating feeling )
Tinnitus / Hearing loss
Work-related hearing discomfort/subjective symptoms
Changes in skin and/or nails *
Changes in vision *
Changes in inside mouth and/or nose *
Others related to work *
Clear selection
Special Notes
Those who chose ( * ) starred items must write details here.
A copy of your responses will be emailed to the address you provided.
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