Please review the information below. If everything is correct, click “Send”. To go back and edit your entries, click “Edit”.
The following required items were not provided or are in the wrong format. Please provide the required responses and submit again:
Section 1:
The purpose of these questions is to collect demographic and background data that will best inform employee experiences with symptoms of burnout.
How long have you worked at this organization?
What best describes your job function?
What is your income?
What is your age?
What is your gender identity?
How do you describe your ethnicity? (Select all that apply.)
American Indian or Alaska Native
Asian
Black
Latino/Latinx or Hispanic
Mixed Race Bi-racial
Native Hawaiian and other Pacific Islander
White
Prefer Not to disclose
Please select all groups that you identify with:
LGBTQ+
BIPOC
Veteran or active military
Person with disability(ies)
Other
Are you a caregiver? (examples of caregivers include but are not limited to: biological parent, adoptive parent, foster parent, legal guardian, caregiver to elderly relative, caregiver to relative with physical or mental disability, chronic illness, caregiver to adult child unable to care for themselves or child with chronic illness or disability)
What is your current employment status?
Which of the following best describes your position?
Please list your most valued wellbeing-supportive benefits that are currently offered at your organization
Please list benefits that you would find valuable in support of your wellbeing that are not currently offered at your organization
Section 2:
These questions will assess your experiences with symptoms of burnout. Please answer honestly; survey responses will be shared with your employer in de-identified summary only. Supportive resources will be shared with you at the end of this survey.
1. I am often physically exhausted
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
2. I am often mentally exhausted
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
3. I have experienced a significant life event and/or trauma within the last year
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
4. I have felt depressed or anxious within the last year
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
5. I participate and/or have participated in healthy coping strategies when I feel exhausted and worn out within the last year (example include, but not limited to: exercise, rest, meditation, journaling, talking with loved ones)
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
6. I participate and/or have participated in unhealthy coping strategies when I feel exhausted and worn out within the last year (example include, but not limited to: drinking alcohol, using substances, withdrawing from loved ones or avoiding social connections)
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
7. I tend to bounce back quickly after challenges
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
8. I am afraid of failure
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
9. I often find joy in my life
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
10. It is difficult for me to set boundaries in my life
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
11. I engage in behaviors that place a strong priority on my physical health
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
12. I engage in behaviors that place a strong priority on my mental health
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
13. I feel financially secure
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
14. Financial challenges are one of my greatest sources of stress
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
15. Thinking of your energy as a gas tank that is full, empty, or somewhere in between - what percent of energy are you operating from on a daily basis? (example: 100% = highest quantity + quality of energy, 0% = lowest quantity + quality of energy)
0-25%26-50%51-74%75-99%100%
Section 3:
These questions will assess work-related factors that may contribute to or influence your experiences with burnout. The factors assessed in this section will include the workplace culture, environment, manager and co-worker relationships, and your experience with your job and workload. Please answer honestly; survey responses will be shared with your employer in de-identified summary only.
16. My company demonstrates a commitment to the wellbeing of employees
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
17. I feel supported in my wellbeing when I’m working
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
18. I have autonomy over my work
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
19. I am treated fairly in my workplace
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
20. I feel emotionally drained by the work I am doing
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
21. I feel frustrated by the work I am doing
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
22. I feel exhausted in the morning at the thought of another day of work
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
23. After work, I have little energy for family and friends
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
24. I am unable to maintain a healthy separation between my work and home life
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
25. After work, I feel worn out and weary
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
26. I have to move from task to task during the work day with no breaks or time to recharge
Strongly Disagree Disagree Neutral Agree Strongly Agree
27. I’m mentally exhausted at the end of the work day but I still don’t feel like I’ve had enough time to attend to what’s most important
Strongly Disagree DisagreeNeutral Agree Strongly Agree
28. When my energy feels depleted, I have the support available to help me at work
Strongly Disagree Disagree Neutral Agree Strongly Agree
29. On average, how many total hours per week do you work?
30. My relationships with my co-workers deplete my energy
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
31. I feel supported by my manager
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
32. My manager genuinely cares about my wellbeing
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
33. My manager asks me how I’m doing regularly
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
34. I really don’t care what happens to my colleagues or clients at my job
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
35. If I choose to make use of flexible working arrangements, I feel supported by my manager
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
36. If I choose to make use of flexible working arrangements, I feel supported by my co-workers
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
37. When my energy is depleted, I feel safe to share this with my manager
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
38. When I am struggling with my wellbeing and/or mental health, I feel safe to share this with my manager
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
39. When I am struggling with my physical health, I feel safe to share this with my manager
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
40. Our company leaders actively communicate wellbeing-supportive messages and information
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
41. My manager actively communicates wellbeing-supportive messages and information
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
42. Our company leaders express the importance of balancing work life and personal life
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
43. My manager expresses the importance of balancing work life and personal life
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
44. There are company norms that make it difficult for me to feel like a balance between work and life is supported or valued (example include, but not limited to: it’s common and expected to work additional hours above and beyond 40, it’s expected to respond to emails all the time/at any time, there is a culture of competition among co-workers, etc.)
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
45. Our company leaders visibly model behaviors that show that they value their own wellbeing
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
46. My manager visibly models behaviors that show that they value their own wellbeing
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
47. I feel supported in my career goals and growth
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree
48. I feel supported by formal policies that are in place to impact my wellbeing while I’m working
Strongly DisagreeDisagreeNeutralAgreeStrongly Agree