your sources of stress, what percentage would you assign to: Work -------- Home -------- 3.Do you think the stress you feel is: Positive Mostly positive Neutral Mostly negative Negative 4. What do you consider the greatest sources of your job stress? Change in duties Increase in work load Relocation New job Implementing layoffs Threat of being laid off Budget cuts New boss Pay inequity Sexual harassment Responsibility without authority Little support from boss Little scheduling flexibility Insensitivity to child-care needs Other 5. Which statement best describes the way stress affects your work performance? I work best with a lot on my plate I can take some stress but not too much (or not all the time) Too much pressure interferes with my performance Other 6. How often would you say you feel stressed-out at work? Frequently (more than three times a week) Once or twice a week Infrequently Rarely 7. Do you feel that your work has become more stressful in the last two years? Yes No 8. How would you describe your work load? Fairly well-balanced and manageable Uneven and unpredictable Too heavy to do a good job 9. Despite work load and other problems, in general do you feel you are in control of your work most of the time? Yes No 10. If you were CEO, what's the first thing you'd do to reduce your workers' stress? Raise salaries Increase vacation time Offer flextime Provide child-care options Change dress code Institute summer hours 11. Which statement best describes the balance between your work and home lives? Juggling the two usually gives me great satisfaction I feel that there's enough time for each My job is taking over my personal life Domestic responsibilities are impeding my career 12. On a typical workday, how many minutes do you spend on household chores? 10-30 - 30-60 60-90 90-120 More than 120 13. If you have children, who takes on most of the responsibility for the kids after work? Me Partner Share equally Caregiver Other family member 14.How much daily leisure time do you have for yourself? Less than 30 minutes 30-59 minutes An hour or more Two hours or more 15. How much stress do you think your spouse/partner is under? Less than I am Equal amount More than I am 16. Do you think you are happier -------- or unhappier -------- than your mother was? 17. Do you think you are more stressed -------- or less stressed -------- than your mother was? 18. Are you under stress at home because you frequently have to: Bring work home Stay late Travel for business None of the above 19. Which of the following has been the greatest source of personal stress in the last year? Death Birth Children Elderly dependent Financial worries Unreliable child care or elder care Worry that my family resents/suffers from the time I spend working nequal responsibilities at home Difficult commute Relationship problems Other 20. Considering the demands of both job and home life, would you say you are: Thriving from the challenge Under stress but in control Too stressed for comfort Unable to function well 21. How do you believe your stress shows up physically? Muscle tension Fatigue Insomnia Headaches Skin outbreaks High blood pressure Digestive problems Overeating Drinking Smoking Other 22. How do you react psychologically to stress? Anger Loss of energy Irritability Nervousness Depression Diminished sex drive Other 23. Has any drug been prescribed to relieve your stress symptoms in the last two years? Yes No 24. If so, what? -------- 25. How many days have you taken off from work in the last year due to stress related physical problems? 0 1-3 4-7 8-10 More than 10 26. Have you ever taken off from work as a way of avoiding stress? Yes No 27. Have you ever left a job to escape stress? Yes No 28. Where do you go for help when you're feeling stressed?: Doctor Therapist Spouse/partner Family member Friend Employee-assistance plan No one Other 29. Whom do you most frequently take your stress out on? Employees Spouse/partner Friends Children Self No one Other 30. How do you deal with a stressful situation? Organise work or home Work harder Ask for help Withdraw 31. Do you feel the way you deal with stress is effective? Yes No 32. Check the three main ways you relieve or head off stress Exercise/sports Sleeping Meditation or other relaxation techniques Drinking Taking drugs Eating Sex Massage or facial Shopping Hobby Watching TV Spending time with spouse/partner, friends, children 33. Do you feel the ways you relieve tension are effective? Yes No 34. What's the biggest intangible toll stress takes on your life? Strained relationship with spouse/partner Strained relationship with children Poor work performance Poor sex life Excessive spending 35. How does your company help relieve job and/or family-related stress? Job flexibility Child-care facilities Stress-management programs Exercise facilities Counselling 36. Which do you think would most reduce stress in your life? More money More time for myself More time with my family More control over/autonomy in my job More help at home More exercise or other stress-reduction techniques Other 37. If you won the lottery, would you: Continue in current job/profession Change job/career Never work again Start own business Volunteer 38. Are you currently: Employed by a large corporation (over 500 employees) Employed by a medium-size company (51-500) Employed by a small business (1-50) Self-employed Running own business (with other employees) Not employed 39. Your sex: Male Female 40. Your age: Under 30 30-39 40-59 50 or over 41. Marital status: Married Single, divorced or widowed (living alone) Single, living with partner 42. If you have children under 18, fill in the number in the appropriate age brackets: 0-5 years 6-12 years 13-18 years 43. Highest level of education you have completed: High school Some college Undergraduate Postgraduate 44. What field are you in? Manufacturing Service Retail Government Banking Education Other 45. What is your job level? Top management Middle management Supervisory Nonsupervisory professional or specialist Support staff Other 46. How many employee report to you? 0 1-5 6-15 16-30 31-50 51-100 More than 100 47. How many hours per week do you put in at work? Under 24 24-32 33-40 41-50 51-60 60-plus 48. Annual income, Household and Individual Less than $15,000 $15,000-$24,999 $25,000-$34,999 $35,000-$74,999 $75,000-$99,999 $100,000 or more 49. Do you provide the majority of the income for the household? Yes No HEALTH HTH