Work Place Assessment

Work Place Assessment

1. Job Satisfaction *

2. Sick days (absenteeism)

What is the number of days you missed from work due to injury or illness within the past 12 months? *

3. Productivity (presenteeism)

How many days did you feel affected negatively your productivity due to adverse mental and/or physical health condition with in the past 12 months? *

4. Work Impediment (presenteeism)

Rate by how much your productivity was negatively affected due to mental and/or physical health condition within the past 12 months? *

5). Health and Wellness Interests *

6). Health and Wellness Culture

Rate your organization overall wellness program(s) *

7). Notification

Contact me by *

8). The absenteeism and presenteeism questions

(i). About how many hours altogether did you work in the past 7 days? (If more than 97, enter 97.)*

(ii). How many hours does your employer expect you to work in a typical 7-day week? (If it varies, estimate the average. If more than 97, enter 97.)*

(iii). Now please think of your work experiences over the past 4 weeks (28 days). In the spaces provided below, write the number of days you spent in each of the following work situations. In the past 4 weeks (28 days), how many days did you...

(a). miss an entire work day because of problems with your physical or mental health? (Please include only days missed for your own health, not someone else’s health.)*

(b). miss an entire work day for any other reason (including vacation)? *

(c). miss part of a work day because of problems with your physical or mental health? (Please include only days missed for your own health, not someone else’s health.) *

(d). miss part of a work day for any other reason (including vacation)? *

(e). come in early, go home late, or work on your day off? *

(iv). About how many hours altogether did you work in the past 4 weeks (28 days)? *

(v). On a scale from 0 to 10 where 0 is the worst job performance anyone could have at your job and 10 is the performance of a top worker, how would you rate the usual performance of most workers in a job similar to yours? *

(vi). Using the same 0-to-10 scale, how would you rate your usual job performance over the past year or two? *

(vii). Using the same 0-to-10 scale, how would you rate your overall job performance on the days you worked during the past 4 weeks (28 days)? *