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What is your job title?
   
 
 
 
What is/are the most stressful aspect(s) of your job?
   
 
 
 
What are the positive aspects of your job?
   
 
 
 
How long have you had this particular job stress?
 
Less Than A Month
 
1-3 Months
 
4-6 Months
 
6 Months - 1 year
 
More than 1 year
 
 
 
How would you rate the level of your job stress?
 
Mild
 
Moderate
 
Severe
 
Extreme
 
 
 
How many attempts have you made to relieve your job stress or solve the problem causing it?
 
None
 
One
 
Two
 
Three or more
 
 
 
Is your job stress caused by your relationship with another person you work with?
 
Yes
 
No
 
 
 
If your job doesn't involve another person, is it caused by the:
 
Volume of work
 
Nature of the job and its responsibilities
 
Physical work environment
 
Personal health issue
 
Other
 
 
 
Do you ever suffer from any of the following?
Never Sometimes Often
Headaches
Anxiety
Chest pain
Indigestion or nausea
Sleeplessness
Irritability
Backache
Neck ache
Inability to concentrate
 
 
Do you find any of the following cause problem?
Never Sometimes Often
Shiftwork
Inadequate break times/mealtimes
Unsocial hours
Very heavy workload
Unfair distribution of work
Repetitive/boring work
Meeting deadlines
Job insecurity, e.g. threat of redundancy
Poor supervision
Under-utilization of skills
 
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