Copyright Health Sponsorship Council. This sheet can be photocopied and adapted for school use only.

This appendix provides examples of the types of questions you could ask in your
surveys depending on your
research objectives. These questions come from the National ASH Year 10 Snapshot
Survey, the Year 10 In-depth
Survey, and the Health and Lifestyles Survey. It is a good idea to use questions that
have been used in national
surveys because they have been developed by researchers and are valid measures. It
also means you can compare
your fi ndings against a benchmark.
The appendix isnt an exhaustive list of questions, but it does provide a starting point for
creating your own
questionnaires. You may also fi nd it useful to look at examples of other questions. Links
to useful surveys are
given at the end of this appendix.

Ethnicity
Which ethnic groups do you belong to?
Please tick
all
boxes that apply
.
New Zealand European
Other Pacifi c Islands nation
Mori
Chinese
Samoan
Indian
Cook Islands Mori
Other Asian
Tongan
Other (Please write in.)
Niue

Smoking status and smoking susceptibility

The standard way to defi ne a survey respondents smoking status is to ask questions
a
and
b
on the next page.


Never smokers: Those who answer no to
a

Experimenter: Those who answer yes to

a
and I have never smoked/I am not a smoker now to
b

Current or regular smokers: Those who answer at least once a day, at least once a
week, or at least once a
month to
b

Daily smokers: Those who answer at least once a day to

b
.
Researchers have also developed two questions that tell us how susceptible young
people who dont smoke are to
taking up smoking in the future.

Non-susceptible never smokers: Those who had never smoked and who answered defi
nitely not to
c
,
d
, and
e

Susceptible never smokers: Those who had never smoked but who answered anything
except defi nitely not
to
c
,
d
, or
e
.
Our Smokefree School He Kura Auahi Kore
A Practical Guide to Being a Smokefree Community
Appendix V:
Sheet 1 of 8

Some possible survey questions

Copyright Health Sponsorship Council. This sheet can be photocopied and adapted for school use only.

Our Smokefree School He Kura Auahi Kore

A Practical Guide to Being a Smokefree Community
Appendix V:
Sheet 2 of 8

a.
Have you ever smoked a cigarette, even just a few puffs?
Ye s
No
b.
How often do you smoke now?
Please tick
one
box only
.
I have never smoked/I am not a smoker now
At least once a day
At least once a week
At least once a month
Less often than once a month
c.
If one of your best friends offered you a cigarette, would you smoke it?
Please tick
one
box only
.
Defi nitely not
Probably not
Probably yes
Defi nitely yes
d.
At any time during the next year (12 months) do you think you will smoke a cigarette?
Please tick
one
box only
.
Defi nitely not
Probably not
Probably yes
Defi nitely yes
e.
Do you think you will try a cigarette soon?
Please tick
one
box only
.
Defi nitely not
Probably not
Probably yes
Defi nitely yes

Quitting attempts
During the past year (12 months), have you ever tried to stop smoking cigarettes?
Please tick
one
box only
.
I have never smoked cigarettes.
I did not smoke during the past year.
Yes, I have tried to stop smoking cigarettes.
No, I have not tried to stop smoking.

Access to tobacco
During the past 30 days (one month), how did you usually get your own cigarettes?
Please tick
one
box only
.
I have never smoked/I am not a smoker now.
I bought them from a shop.
I bought them from a
vending machine.
A friend/friends or person my age gave them to me.
A parent or caregiver gave them to me.
I took them from a parent or caregiver without asking.
I got them from an older brother or sister.
I got them some other way.
Copyright Health Sponsorship Council. This sheet can be photocopied and adapted for school use only.

Attitudes towards tobacco use

You could use a selection of the following questions to fi nd out what your students think
about smoking and smokers.
For each statement listed below, please indicate whether you agree or disagree with it.
Please tick
one
box for each statement
.
1. Smokers are more popular.
Agree
Disagree
Dont know
2. Smoking helps people forget their worries.
Agree
Disagree
Dont know
3. Non-smokers dislike being around people who are smoking.
Agree
Disagree
Dont know
4. Smokers find it hard to get dates.
Agree

Disagree
Dont know
5. Smokers are tough.
Agree
Disagree
Dont know
6. Smoking is something you need to try before deciding to do it or not.
Agree
Disagree
Dont know
7. Smoking makes people look more grown-up.
Agree
Disagree
Dont know
8. There is no harm in having a cigarette once in a while.
Agree
Disagree
Dont know
9. Smoking helps people relax.
Agree
Disagree
Dont know
10. Seeing someone smoking turns me off.
Agree
Disagree
Dont know
11. Smokers are often stressed.
Agree
Disagree
Dont know
12. Smoking is enjoyable.
Agree
Disagree
Dont know
13. Smoking makes people look sexy.
Agree
Disagree
Dont know
14. Non-smokers should be proud to be smokefree/auahi kore.
Agree
Disagree
Dont know
Our Smokefree School He Kura Auahi Kore
A Practical Guide to Being a Smokefree Community
Appendix V:
Sheet 3 of 8
Copyright Health Sponsorship Council. This sheet can be photocopied and adapted for school use only.

Our Smokefree School He Kura Auahi Kore

A Practical Guide to Being a Smokefree Community
Appendix V:

Sheet 4 of 8

Attitudes towards tobacco regulation, the tobacco industry, and

the idea of a smokefree/auahi kore New Zealand
For each statement listed below, please indicate whether you agree or disagree with it.
Please answer every question.
Tick
on
e
box on each line
.
1. Smoking should be banned in all outdoor places where young people go.
Agree
Disagree
Dont know
2. There should be fewer places where cigarettes and tobacco can be sold.
Agree
Disagree
Dont know
3. Tobacco companies should not be allowed to promote cigarettes and tobacco with
cool-looking packs.
Agree
Disagree
Dont know
4. Cigarettes and tobacco should be made more expensive so that children and
young people cant afford to
buy them.
Agree
Disagree
Dont know
5. Cigarettes and tobacco should not be sold in New Zealand in 10 years time.
Agree
Disagree
Dont know
6. Its not OK for people to smoke around me where I can breathe their smoke.
Agree
Disagree
Dont know
7. I want to live in a country where no one smokes.
Agree
Disagree
Dont know

Knowledge of harm
1. Do you think cigarette smoking is harmful to your health?
Please tick
one
box only
.
Defi nitely not

Probably not
Probably yes
Defi nitely yes
2. Do you think the smoke from other peoples cigarettes is harmful to you?
Please tick
one
box only
.
Defi nitely not
Probably not
Probably yes
Defi nitely yes

Smoking by family, friends, and teachers

Which of the following people smoke?
Please tick
all
that apply
.
Best friend
Other close friends
Father
Mother
Grandparents
A teacher at school
Other caregiver (e.g., stepfather or stepmother, foster parents)
Older
brother(s)
Older
sister(s)
None of the above
Copyright Health Sponsorship Council. This sheet can be photocopied and adapted for school use only.

Our Smokefree School He Kura Auahi Kore

A Practical Guide to Being a Smokefree Community
Appendix V:
Sheet 5 of 8

Second-hand smoke exposure

During the past 7 days, on how many days have people smoked around you in your home?
Please tick
one
box only.
0
1 to 2
3 to 4
5 to 6
7
During the past 7 days, on how many days have people smoked in your presence in places
other than in your home?
Please tick
one

box only
.
0
1 to 2
3 to 4
5 to 6
7
During the past 7 days, on how many days have people smoked around you in your home?
Please tick
one
box only
.
0
1 to 2
3 to 4
5 to 6
7

Exposure to the role-modelling of smoking

During the past month (30 days), how often have you noticed people smoking in the
following places?
Please tick
one
box
for
each
place
.
1. Local parks or reserves
A lot
Sometimes
Never
Didnt go there
2. Outdoor childrens playgrounds
A lot
Sometimes
Never
Didnt go there
3. At school
A lot
Sometimes
Never
Didnt go there
4. Outdoor sports fi elds or courts
A lot
Sometimes
Never
Didnt go there
5. Outdoors at a marae

A lot
Sometimes
Never
Didnt go there
6. Outside doorways to public buildings
A lot
Sometimes
Never
Didnt go there
7. Beaches
A lot
Sometimes
Never
Didnt go there
8. Outdoor seating areas of bars/restaurants/cafes
A lot
Sometimes
Never
Didnt go there
Copyright Health Sponsorship Council. This sheet can be photocopied and adapted for school use only.

Our Smokefree School He Kura Auahi Kore

A Practical Guide to Being a Smokefree Community
Appendix V:
Sheet 6 of 8

Young peoples reporting of parental rules and monitoring around

smoking
For each statement listed below, please indicate whether you agree or disagree with it.
Please tick
one
box for
each
statement
.
1. My parents or caregivers have set rules with me about not smoking cigarettes or
tobacco.
Agree
Disagree
Dont know
2. My parents or caregivers generally know what I spend my pocket money on.
Agree
Disagree
Dont know
3. My parents or caregivers have rules about when I can go out with my friends.
Agree
Disagree
Dont know
4. My parents or caregivers often have no idea where I am when I am away from my
home.
Agree

Disagree
Dont know
5. My parents or caregivers know about my school life (e.g., my teachers, my grades).
Agree
Disagree
Dont know
6. My parents or caregivers would be upset if I was caught smoking cigarettes or
tobacco.
Agree
Disagree
Dont know
7. If I break any important rules that my parents or caregivers have set, I always get
into trouble.
Agree
Disagree
Dont know
Copyright Health Sponsorship Council. This sheet can be photocopied and adapted for school use only.

Our Smokefree School He Kura Auahi Kore

A Practical Guide to Being a Smokefree Community
Appendix V:
Sheet 7 of 8

Parenting and tobacco

This includes the extent to which parents believe they can infl uence whether their
children smoke and the extent to
which they tell their children not to smoke. Your choice of questions will depend on the
age of the children.
As a parent or caregiver, do you have any infl uence over whether Xxx starts to smoke
cigarettes or tobacco?
Ye s
No
Not applicable child too young
Other
Dont know
Refused
Do you think you will have any infl uence over whether Xxx starts to smoke cigarettes or
tobacco when he or she
is older?
Ye s
No
Dont know
Refused
Do you think you are able to prevent Xxx from starting to smoke cigarettes or tobacco?
Ye s
No
Not applicable child too young
Other
Dont know
Refused

Do you think you will be able to prevent Xxx from starting to smoke cigarettes or tobacco
when he or she is older?
Ye s
No
Dont know
Refused
How often do you tell Xxx that you dont want him or her to smoke cigarettes or tobacco?
Never
Rarely
Sometimes
Often
Very often
Not applicable/Other
Dont know
Refused
Do you have set rules with Xxx about not smoking cigarettes or tobacco?
Ye s
No
Not applicable/Other
Dont know
Refused

More questions
ASH Year 10 Snapshot Survey
This survey is conducted yearly and is used to work out smoking rates among 14-15year-old students. If your school
has year 10 students, you would have received an invitation to participate. Action on
Smoking and Health (ASH)
provides schools with their own school-level smoking rates for year 10 students. You
may fi nd this information useful
for informing or evaluating your smokefree activities.
The questionnaires from these surveys are available on the Internet at
www.ash.org.nz/?t=182

Year 10 In-depth Survey

The Health Sponsorship Council (HSC) has conducted this survey biennially, in 2006,
2008, and 2010. It includes
questions on:

attitudes and behaviours around smoking (for example, attitudes towards tobacco
companies, on whether smoking
should be allowed in cars, in movies, or in magazines, on effectiveness in quitting, on
the extent to which respondents
got help to quit)

other known protective or risk factors for smoking uptake, for example, connectedness
to schools, peers, and family


access to tobacco (for example, experiences of trying to buy tobacco)

where people smoke.

The questionnaire is available on the Internet at
http://www.hsc.org.nz/researchpublications.html
Copyright Health Sponsorship Council. This sheet can be photocopied and adapted for school use only.

Our Smokefree School He Kura Auahi Kore

A Practical Guide to Being a Smokefree Community
Appendix V:
Sheet 8 of 8

The Health and Lifestyles Survey (HLS)

The Health Sponsorship Council started the Health and Lifestyles Survey (HLS) in
2008, and it was conducted again
in 2010. It includes questions on topics such as smoking, quitting, what prompted
quitting, attitudes towards smoking
in outdoor areas, the extent to which smoking or tobacco is seen as a problem, attitudes
to tobacco regulation, and
parental infl uence on smoking.
This survey is available on the Internet at
http://www.hsc.org.nz/researchpublications.html

Centers for Disease Control Question Inventory on Tobacco

Centers for Disease Control Question Inventory on Tobacco is a searchable database of
tobacco survey questions.
The database is available on the Internet at
http://apps.nccd.cdc.gov/qit/QuickSearch.aspx

The New Zealand Tobacco Use Survey

The Ministry of Healths New Zealand Tobacco Use Survey (NZTUS) also has
standardised questions.
This questionnaire is available on the Internet at
http://www.moh.govt.nz/moh.nsf/indexmh/dataandstatistics-survey-tobaccouse
Since April 2011, the NZTUS has been integrated into the New Zealand Health Survey.
See http://www.moh.govt.nz/moh.nsf/indexmh/dataandstatistics-survey-nzhealth

International Tobacco Control Policy Evaluation Project

The New Zealand arm of this project is run by the University of Otago Wellington School
of Medicine. The
questionnaire is available on the Internet at
http://www.wnmeds.ac.nz/academic/dph/research/HIRP/Tobacco/
itcproject.html

Global Schools Personnel Survey

If you are wanting to survey school staff, some of the questions from this survey might
be useful. Topics covered are
tobacco use, attitudes and knowledge, school procedures, and school curriculum. Note
that some of the questions
wont be relevant in the New Zealand context.

This questionnaire is available on the Internet at

http://www.cdc.gov/tobacco/global/gsps/questionnaire/index.htm

http://www.stress.org/wp-content/uploads/2011/08/Workplace-Stress-Survey.pdf

Workplace Stress Survey http://www.stress.org/wpcontent/uploads/2011/08/Workplace-Stress-Survey.pdf

Enter a number from the sliding scale below, which best describes you.
STRONGLY DISAGREE
AGREE SOMEWHAT
STRONGLY AGREE

1 2 3 4 5 6 7 8 9 10
I cant honestly say what I really think or get things off my chest at work.
______
My job has a lot of responsibility, but I dont have very much authority.
______
I could usually do a much better job if I were given more time.
______
I seldom receive adequate acknowledgement or appreciation when my
work is really good.
______
In general, I am not particularly proud or satisfied with my job.
______
I have the impression that I am repeatedly picked on or discriminated against at
work. ______
My workplace environment is not very pleasant or safe.
______
My job often interferes with my family and social obligations, or personal needs.
______
I tend to have frequent arguments with superiors, coworkers or customers.
______
Most of the time I feel I have very little control over my life at work. ______
Add up the replies to each question for your TOTAL JOB STRESS SCORE
______

If you score between 10

30, you handle stress on your job well; between 40
-

60, moderately well; 70

100 you are encountering problems that need to be resolved.

WORK
RELATED STRESS
QUESTIONNAIRE
This questionnaire is closely based on the
Management Standards
Indicator Tool produced by the HSE (Health and
Safety Executive).
The Management Standards define the
characteristics, or culture, of
an organisation wher
e the risks from work
related stress are being
effectively managed and controlled.
The questionnaire is being issued by
UNITE
Health and Safety
Representatives within Fujitsu following
reports

of work
related
stress in
some
parts of ITG.
The enclosed cover
ing letter provides more information.
Instructions: It is recognised that working conditions affect worker well
being. Your responses to
t
he questions below will help us determine our working conditions now, and
enable us to
monitor future improvements
. In order for us to compare the current situation with past or
future situations,
it is important that your responses reflect your work in the last six months
.
1.
I am clear what is expected of me at work
Never
1
Seldom
2
Sometimes
3
Often
4
Always
5

2.
I can decide when to take a break
Never
1
Seldom
2
Sometimes
3
Often
4
Always
5

3.
Differ
ent groups at work demand things from me that

are hard to combine

Never
5
Seldom
4
Sometimes
3
Often
2
Always
1

4.
I know how to go about getting my job done
Never
1
Seldom
2
Sometimes
3
Often
4
Always
5

5.
I am subject to personal harassment in the form of
unkind words or behaviour
Never
5
Seldom
4
Sometim
es
3
Often
2
Always
1

6.
I have unachievable deadlines
Never
5
Seldom
4
Sometimes
3
Often
2
Always
1

7.
If work gets diffi
cult, my colleagues will help me
Never
1
Seldom
2
Sometimes
3
Often
4
Always
5

8.

I am given supportive feedback on the work I do

Never
1
Seldom
2
Sometimes
3
Often
4
Always
5

9.
I have to work very intensively
Never
5
Seldom
4
Sometimes
3
Often
2
Always
1

10.
I have a say in my own work speed
Never
1
Seldom
2
Sometimes
3
Often
4
Always
5

11.
I am clear what my duties and responsibilities are
Never
1
Seldom
2
Sometimes
3
Often
4
Always
5

12.
I have to neglect some tasks because I have too much
to do
Never
5
Seldom
4
Sometimes
3
Often
2
Always
1

13.
I am clear about the goals and objectives for my
department
Never

1
Seldom
2
Sometimes
3
Often
4
Always
5

14.
There is friction or anger be
tween colleagues
Never
5
Seldom
4
Sometimes
3
Often
2
Always
1

15.
I have a choice in deciding how I do my work
Never
1
Seldom
2
Sometimes
3
Often
4
Always
5

16.
I am unable to take sufficient breaks
Never
5
Seldom
4
Sometimes
3
Often
2
Always
1

17.
I understand
how my work fits into the overall aim of
the organisation
Never
1
Seldom
2
Sometimes
3
Often
4
Always
5

18.
I am pressured to work long hours
Never
5

Seldo
m
4
Sometimes
3
Often
2
Always
1

19.
I have a choice in deciding what I do at work
Never
1
Seldom
2
Sometimes
3
Often
4
Alw
ays
5

20.
I have to work very fast
Never
5
Seldom
4
Sometimes
3
Often
2
Always
1

21.
I am subject to bullying at work
Never
5
Seldom
4
Sometimes
3
Often
2
Always
1

22.
I am aware of others being subject to bullying at work
Never
5
Seldom
4
Sometimes
3
Often
2
Alw
ays
1

23.
If I were aware of bullying I would feel able to
challenge it
Never
1
Seldom

2
Sometimes
3
Often
4
Always
5

24.
If I reported bullying, I would be con
fident that it
would be stopped
Never
1
Seldom
2
Sometimes
3
Often
4
Always
5

25.
I have unrealistic time pressures
Never
5
Seldom
4
Someti
mes
3
Often
2
Always
1

26.
I can rely on my line manager to help me out with a
work problem
Never
1
Seldom
2
Sometimes
3
Often
4
Always
5

27.
I get help and support I need from colleagues
Strongly
disagree
1
Disagree
2
Neutral
3
Agree
4
Strongly
agree
5

28.
I have some say over the way I work
S

trongly
disagree
1
Disagree
2
Neutral
3
Agree
4
Strongly
agree
5

29.
I have sufficient opportunities to question managers
about change at work
Strongly
disagree
1
Disagree
2
Neutral
3
Agree
4
Strongly
agree
5

30.
I receive the respect at work I deserve from my
colleagues
Strongly
disagree
1
Disagree
2
N
eutral
3
Agree
4
Strongly
agree
5

31.
Staff are always consulted about change at work
Strongly
disagree
1
Disagree
2
Neutral
3
Agree
4
Strongly
agree
5

32.
I can talk to my line manager about something that has
upset or annoyed me about work
Strongly
disagree
1
Disagree
2

Neutral
3
Agree
4
Strongly
agre
e
5

33.
My working time can be flexible
Strongly
disagree
1
Disagree
2
Neutral
3
Agree
4
Strongly
agree
5

34.
My working location can be flexible (subject
to
business constraints)
Strongly
disagree
1
Disagree
2
Neutral
3
Agree
4
Strongly
agree
5

35.
My colleagues are willing to listen to my work
related
problems
Strongly
d
isagree
1
Disagree
2
Neutral
3
Agree
4
Strongly
agree
5

36.
When changes are made at work, I am clear how they
will work out in practice
Strongly
disagree
1
Disagree

2
Neutral
3
Agree
4
Strongly
agree
5

37.
I am supported through emotionally demanding work
Strongly
disagree
1
Disagree
2
Neutral
3
Agree
4
Strongly
agree
5

38.
Relationships at work are strained
Strongly
disagree
5
Disagree
4
Neutral
3
Agree
2
Strongly
agree
1

39.
My line manager encourages me at work
Strongly
disagree
1
Disagree
2
Neutral
3
Agree
4
Strongly
agree
5

Thank you for completing the questionnaire.

Please re
turn, as hardcopy, to Phil Tepper at MAN34.
http://www.ourunion.org.uk/news/archives/Stress%20Questionnaire.pdf

1
Introduction
Brought to you by: American Institute for Preventive Medicine
2
Stress Management at Work
3
Type A & B Behavior Patterns
4
Biofeedback Training and Relaxation
5
Thinking Differently
6
Time Management
Home
7
Communication and Stress
Stress Management at Work

Work Stressor Questionnaire

Work stressors can be identified in almost all aspects of ones job. Before taking action to
eliminate or reduce these stressors, pinpoint their sources. Isolate these factors so corrective
action can begin.

Instructions: Think about how often you encounter the following situations. Rate yourself with
the following scale in each category.
1 = Never

2 = Rarely
3 = Occasionally
4 = Usually
5 = Constantly

A. Disagreement & Indecision

Unsure of coworkers expectations
Unfriendly attitude in coworkers
Job responsibilities go against your better judgment.
Cant satisfy conflicting demands from superiors
Trouble refusing overtime

Section subtotal: 5

B. Pressure on the Job

Overloaded at work, unable to complete tasks during an average day
Too much supervision
Job requirements are taking their toll on your private life
Rushed to complete work or short on time
Too much red tape

Section subtotal: 5

C. Job Description Conflict

Uncertainty about your exact job responsibilities
Too much teamwork
Poor flow of information to you in order to carry out your job
Not enough authority for you to properly do your job
Discomfort in handling unethical assignments

Section subtotal: 5

D. Communications & Comfort with Supervisor

Ideas differ from those of your supervisor
Trouble talking to boss
Unable to predict supervisors reactions
Boss gives little feedback about your work
Boss is overly critical of your work

Section subtotal: 5

E. Job Related Health Concerns

Work conditions are unhealthy
Physical dangers exist at work place
Heavy physical tasks to complete
Hostile threats from co-workers

Sick days are discouraged

Section subtotal: 5

F. Work Overload Stress

Cant consult with others on projects
Co-workers are inefficient
Often take work home to complete
Responsible for too many people/projects
Shortage of help at work

Section subtotal: 5

G. Work Underload Stress

Too little responsibility at work
Overqualified for your job
Little chance for growth exists
Trying to look busy on job
Feeling unstimulated

Section subtotal: 5

H. Boredom Induced Stress

Repetitive or highly specialized routine

Not learning anything new
Cant see final outcome of your efforts
Job is too easy
Daydreaming frequently

Section subtotal: 5

I. Problem of Job Security

Fear of being laid off or fired
Worry about poor pension
Concerned about low wages
Need pull to get ahead
Could be fired without cause

Section subtotal: 5

J. Time Pressure
Constant reminders that time is money
Starting and ending times are rigid
Monotonous pace of work
Not enough break or meal time
Work pace is too fast

Section subtotal: 5

K. Job Barrier Stress

Hope for advancement or raise is limited
Sex/age discrimination exists at job
Not suited to job
Work has no personal meaning
Work goes unrecognized

Section subtotal: 5

How to Score: Add the numbers you circled within each of the areas and record them. Place a
star (*) next to the highest scoring category.

A. Disagreement & Indecision

B. Pressure on the Job
C. Job Description Conflict
D. Communication & Comfort with Supervisor
E. Job Related Health Concerns
F. Work Overload Stress
G. Work Underload Stress
H. Boredom Induced Stress
I. Problem of Job Security

J. Time Pressure
K. Job Barrier Stress

Your Total Score: 55

Within each area, scores will range from 5 to 25. Scores of 14 or above suggest problem areas.

Overall scores will fall within the 55 to 275 range. Scores of 135 or above would suggest an
unusual amount of work related stress. Use the Ten Tips for Preventing Burnout in the next
section to combat the effects of work related stress.

Next Topic

Disclaimer
Copyright 2012, 4th edition. American Institute for Preventive Medicine. All rights reserved.
http://www.healthylife.com/online/stress/stateofmichigan/work-stessorquestionnaire.html

1
WORKSAFE VICTORIA
/ STRESSWISE PREVENTING WORK-RELATED STRESS IN THE PUBLIC SECTOR

ATTACHMENT 2
SAMPLE SURVEY QUESTIONS FOR
WORK-RELATED STRESS
2. SAMPLE SURVEY QUESTIONS FOR WORK-RELATED STRESS
The following questions cover the areas that have been found to be the main sources of
stress for people at work.
Please tick the box that most accurately reflects how you feel about your job at the moment.

Please only tick ONE box for each question.

1. I have unrealistic time pressures
Often Sometimes Seldom Never/almost never
2. Staff are consulted about change at work
Often Sometimes Seldom Never/almost never
3. I have some say over the way I work
Often Sometimes Seldom Never/almost never
4. I am clear about what my duties and responsibilities are
Often Sometimes Seldom Never/almost never
5. I receive the respect I deserve from my colleagues at work
Often Sometimes Seldom Never/almost never
6. Staff are exposed to interpersonal conflict at work
Often Sometimes Seldom Never/almost never
7. My line manager encourages me at work
Often Sometimes Seldom Never/almost never
Source: Cousins R, Mackay C, Clarke S, Kelly C, Kelly P and McCaig R,
Management Standards and work-related stress in the UK: Practical development, Work and Stress:
a journal of work, health and organisation,
18(2), 2004, p.130; and www.hse.gov.uk/stress
Note: Privacy and confidentiality of personal information must be protected. Personal information is
information or opinion, wh
ether true or not about an identifiable individual.
It should not be possible to identify an individual from workplace records, survey data or workplace
consultation, therefore gr
ouped or aggregate information is recommended
to protect the identity of individuals.
Only persons authorised to handle personal information should summarise, aggregate or de-identify
personal information.

https://www.worksafe.vic.gov.au/__data/assets/pdf_file/0008/12230/stresswise_att_2
.pdf