Please choose the single answer which best applies to your working situation unless otherwise specified. Feel free to write your comments.
1. Total number of working years:____________________ 2. What is your current occupation (please be as precise as possible)? _____________________________________________________
3. What is the total number of years that you worked in your current occupation? ___________years
4.Have you worked at other jobs besides your current one? Yes No If yes, please list the jobs you've had number of years at each: __________________ From (year): _____________ To (year):____________________ __________________ From (year): _____________ To (year):____________________ __________________ From (year): _____________ To (year):____________________ __________________ From (year): _____________ To (year):____________________
Work hours and scheduling
5. How long does your work day usually last? ________hours Do you ever work longer than that? Yes No If yes, how often?________ and for how many hours/day?________
*Do you have a regular work schedule? Yes No *If yes, when do you begin work? _____________ End work:________________
6. How many days do you work per week?_________
*How many weeks of paid vacation to you have per year?_______________
7. Do you work at another job outside your regular one? Yes No If yes, how many hours per week?_________ What do you do? ___________________
8. Do you always have at least one break during your work day? Yes No If yes, how many breaks do you usually have?_______ How long is your usual break?___________
9. Do you work the late night shift (after midnight?) Yes No If yes, do you work the night shift: a. Constantly b. On a rotating basis (describe please how this rotates:_____________________________)
Mode of Payment and Evaluation
10. My pay is: a. Based upon how much I myself work b. Based upon how much my group or collective, as whole, works c. Fixed
11. How is your work evaluated? a. No one but me evaluates my work b. A supervisor or other responsible person evaluates my work, there are no rigid standards and generally if it is done properly, it is accepted c. A supervisor or other responsible person evaluates my work very carefully according to a strict standard. If, for any reason, even a minor one, it does not fully meet these standards, my work may be rejected.
Physical Working Conditions 12. Are you exposed to welding or any other strong lights during work? a. Yes, often b. Sometimes c. Rarely or never
13.Are you exposed to noise at your workplace? a. Yes, it's very noisy and I must raise my voice to be heard by someone right next to me. b. Somewhat, but I can speak normally and be heard by someone next to me. c. No, my workplace is not noisy.
14. Do you perform heavy lifting at work? a. Yes, often times during the day lift 50 kg. ( 110 lbs) or more. b. Yes, I lift from 20 to 50 kg loads (44 - 110 lbs) during my usual work day. c. Yes, I lift up to 20 kg (44 lbs) during my usual work day. d. No, I rarely or never lift anything heavy during work.
15. Are you exposed to vibration at work? a. Yes. Source:___________ Approximate number of hours/day:__________ b. Rarely or never
16. Does it get hot at your workplace? a. Not more than 30 degrees C (86 degrees F) b. It gets hotter than 30 degrees C (86 degrees Ft), but not >40C (103 F). c. Extremely. It can get hotter than >40 C(103 F).
17. Does it get cold at your workplace? a. Not less than 15 degrees C (60 degrees F). b. It can get colder than 15 degrees C/ 60 degrees F, but not less than 10 degrees C/ 50 degrees F. c. I work outside in the wintertime where it is often less than 10 degrees C/ 50 degrees F.
18.Are you exposed to gases, mists or dusts at your workplace? a. No b. Yes, occasionally c. Yes, often. If you answered (b) or (c), please list the chemicals to which you are exposed: ______________________________________________________________________ ______________________________________________________________________
19. What is your body position and activity during work? a. I am constantly in motion, with no fixed body position. b. I mainly work in a single position, but I am free to move about. c. My body position is fixed during work, and my motion is restricted. If you answered (b) or (c), please describe your body position during work: ______________________________________________________________________
20. Do you work in a: a. Hall, large office or outside? b. Small office or workshop? c. Very confined space? If you answered (b) or (c), please state the dimensions:___________________________
21. Do you work in dangerous conditions? (please check all that apply to you) a. Yes, I work on heights or in a workplace in which objects can fall on us. b. Yes, I work with flammable material. c. Yes, I am in danger of being physically assaulted. d. Yes, I am exposed to danger at work due to:___________________________ e. No
Work Accidents and Injuries 22. Have you ever had an accident or been injured (including assault) at work? a. No b. Yes, only of a minor nature c. Yes, I have had one or more serious accidents or have suffered serious physical harm at work: Please briefly describe all serious accidents or injuries _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
23. Have you ever witnessed a serious accident at work? a. Yes, I have observed one or more accidents with a fatal outcome. b. Yes, I have observed one or more serious accidents, but I have never witnessed a fatal outcome. c. I have heard about serious or fatal accidents at work, but never seen this. d. No, I have never witnessed or heard about a serious accident at work.
Time Pressure at Work 24. Do you have a deadline by which a given job or task must be completed? a. Often b. Sometimes c. Rarely or never
25. Do you face speed-up? a. Every day b. At least once a week, but not every day. c. At certain periods of every month d. At certain periods of the year e. Rarely of never
Problems at Work 26. If you don't manage to remember some work-related information: a. I can fairly easily retrieve the information. b. The information can't be retrieved, and sometimes it could have been important. c. The information can't be retrieved, and often the information is very important. I must therefore be very careful to register and remember the information when it is first presented.
27. If you encounter some dilemma during work, and are not certain how to proceed: a. I can usually postpone a decision until the situation is clarified. b. Sometimes I must act based upon the information I have at a given moment, and can't postpone the decision. c. Most of the time I must act based upon the information I have at a given moment, and can't postpone the decision.
28. If you were to make a mistake during work, what are the most serious possible consequences: a. I can usually correct the error. b. There could be irreparable material or other damage. c. The outcome could be fatal.
29. Do you receive clear instructions and information concerning your work? a. Yes, usually or always. b. No, sometimes these are unclear. c. No, often these are unclear.
30. Does it happen that you don't receive all the needed instructions and information concerning your work? a. Yes, there is often missing information. b. Occasionally there is missing information. c. No, rarely or never is there missing information.
31. Do you receive conflicting/contradictory information or instructions about the work you should be doing? a. Yes, often. b. Yes, sometimes. c. No, rarely or never.
32. Does it happen that due to unforeseen circumstances the plan of work changes? a. Yes, often. b. Yes, sometimes. c. No, rarely or never.
33. When there are several work tasks to perform: a. It is usually possible to complete everything without much trouble. b. Even with maximal efforts, it is sometimes impossible to complete everything. c. Even with maximal efforts, it is often impossible to complete everything.
34. Regarding technical problems that prevent you from proceeding with your work (e.g. computer breakdown, power failure, faulty parts, lack of needed supplies, etc.) a. We have a lot of those problems. b. Occasionally such technical problems happen. c. Such problems are rare at my workplace, usually I can proceed with my work without disturbances of that kind.
35. Objectively, how are interpersonal relations at your workplace? a. Excellent, we all get along together and misunderstandings are rare. b. Fair, sometimes there are misunderstandings and tension among us. c. Poor, there is a lot of tension and conflict among us.
Description of your work tasks 36. Please list each of the main work tasks that you perform (Fill in as many lines as you need) _______________________________________ _________________________________ _______________________________________ _________________________________ _______________________________________ _________________________________ _______________________________________ _________________________________ _______________________________________ _________________________________ _______________________________________ _________________________________
37. Please list the tools/equipment/apparatus that you use during work: (Fill in as many lines as you need) _______________________________________ _________________________________ _______________________________________ _________________________________ _______________________________________ _________________________________ _______________________________________ _________________________________ _______________________________________ _________________________________ _______________________________________ _________________________________
38. Are your work tasks monotonous? a. No, a given task always has its particular qualities, so it's never exactly the same. b. Some of my tasks are monotonous, the same thing over and over again. c. Most of my tasks are monotonous, the same thing over and over again.
39. Does it occur that during your work hours, you have nothing to do? a. Yes, often b. Occasionally c. Rarely or never. I always have something to do during my work hours
40. How many different tasks or operations do you perform simultaneously? a. One, or at the most two tasks. b. Occasionally three or more. c. Often three or more. If you answered (b) or (c), please list these:_____________________________ ________________________________________________________________
41. Do any of your tasks have to be performed with a particular speed? a. No. b. Some tasks require speed. c. Many or most of the tasks that I perform require speed: If you answered (b) or (c), please list these:_____________________________ ________________________________________________________________
42. Can you control the speed at which you work? a. Yes, completely since I work independently from others. b. Only partially, since the speed at which I work affects the work of others in my work group. c. Not at all. I work on an assembly or other paced system, and I have no control over the speed at which I work.
Decision-making at work 43. Do you make decisions that affect the work of others? a. No. b. Yes, I work as a supervisor or in a similar capacity, and must oversee the work of others. c. I am not a supervisor, but sometimes I must oversee the work of others. If you answered (b) or (c), how many people to you oversee?______ What are the job profiles of the people whom you oversee? ________________________ ______________________________ ________________________ ______________________________ ________________________ ______________________________ 44. Do you make decisions at your workplace or mainly carry out the decisions made by others? a. All the decisions have been made by others, I only carry out the tasks given to me, and make no decisions, not even about the smallest details. b. The decisions have been made by others. I don't decide even about the details. But my judgment is necessary during work. c. The major decisions have been made by others, but I can decide on my own about the details. d. Sometimes I must make major decisions, and take the responsibility for these. e. My job is mainly comprised of making major decisions.
45. If you make decisions in your work, describe, as best you can, by an example, how you go about it: Example of a decision:__________________ Steps in the decision-making process: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________
46. Must you make rapid decisions or quickly assess a given situation? a. Yes, often b. Occasionally c. No, rarely or never. If you answered (a) or (b), please briefly describe these situations:____________ ________________________________________________________________
47. Concerning conclusions that are decided upon: a. There is usually only one correct decision to be made. b. There are a limited number of correct decisions to be made. c. There are many possible correct decisions to be made.
48. Is there a defined way of solving problems in your work? a. No, I must think up the strategy myself in order to solve problems, and that often requires imagination and creativity. b. There are a few variations, but the basic strategy has already been defined. c. There is a strictly-defined strategy to solve problems for my work.
Interactions with People and with Machines 49. Communication with other people during work: a. There is no need for work-related communication with others. b. From time to time, I must discuss with others in order to perform my work properly. c. Communication with other people is a major feature of my work.
50. If you use gauges, meters or other such devices at your job: How many measuring devices do you use?_____________ Please list these:_________________________________
51. Do you oversee the work of one or more machines or automatic devices? Yes No If yes, how many devices do you follow simultaneously?___________ Can you control the speed at which these devices operate? Yes No
52. How many people do you have under your on-going care/responsibility at work? (e.g. pupils, patients, clients) a. None b. One to five c. Six to ten d. Eleven to twenty e. Over twenty
53. With how many people do you interact daily at work (both fellow employees and the public)? a. None b. One to five c. Six to ten d. Eleven to twenty e. Over twenty
54. How many telephone calls do you receive during a normal working day? (including calls that are meant for others) a. None b. One to five c. Six to ten d. Eleven to twenty e. Over twenty
55. Does it happen during your work day that several people seek your attention at the same time? (including people on the telephone) a. Yes, many times each day b. Yes, a few times each day c. Yes, but only once or twice each day d. No, rarely or never.
56. If several people seek your attention at the same time, how many are they? a. Two at the most b. Usually two, but sometimes more. c. Usually three or more
57. For how many people at your workplace do you perform tasks? a. None b. One c. Two to three d. Four to ten e. Over ten What are their positions? ________________________________________________________________ ________________________________________________________________
Recent changes in your working conditions 58. In the past six months has there been: (Please check all which apply) a. An increase in the length of your work day? b. A decrease in the length of your work day? c. Increased time pressure/number of deadlines? d. An increase in work responsibility? e. Demotion with pay cut? f. Promotion with pay raise? g. Threat of being laid off? h. Other changes, please specify:_________________________________________
Some open-ended questions about your current work: 59. What could be done to improve working conditions at your current job?
60. Which of the above suggestions do you consider to be the most important?
61. What is the most difficult aspect of your job?
62. What do you think could be done to make that difficulty less of a burden?
63. What is the best part(s) about being your job?
64. If attempts were made to improve the conditions for your job, what would you suggest to preserve the good aspects of your work as it now stands?
65. Other comments:
UNDERLOAD Homogeneous Information IU1 0 Heterogeneous information Question 38=a, Q. 36-37 several tasks, OR Q. 51- 57 (interacts with persons or several machines) 1 Moderately homogeneous information Question 38=b or c AND Q. 36-37 a few tasks AND Q. 51 - 57 (limited interactions with persons / few machines) 2 Maximally homogeneous information Question 38=c AND Q. 36-37 very few, simple tasks AND Q 49=a, Q. 51-57 (minimal interactions with persons / few machines)
Low frequency of incoming signals IU2 0 Question 42=a & 51=yes (controls speed him or herself) OR >1 new signal/minute (overall assessment, see especially Questions 51-57) 2 Question 42=b or c OR 51=no (doesn't control speed) AND <1 new signal per minute (overall assessment, see especially Questions 51-57)
No need for communication IU3 2 Question 49=a (no need for communication with others) 0 Question 49=b or c (works with others)
Automatic decision-making CU3 2 Question 44=a (Fully automatic)AND Question 43=a (No supervisory work) 1 Question 44=b (Automatic but judgment required)AND Question 43=a (No supervisory work) 0 Question 44=c, d or e (Not automatic)OR Question 43=b or c (supervisor)
Homogeneous Tasks OU1 2 Question 38=c (Homogeneous tasks)AND Question 36=Two or fewer tasks 1 Question 38=b or c (Homogeneous tasks)AND Question 36= Three or more tasks 0 Question 38=a Heterogeneous tasks
Simple Tasks OU2 2 Question 36 & 37 (Few steps) 0 Question 36 & 37 (Several steps)
Nothing to do OU3 2 Question 39=a (Often nothing to do) 1 Question 39=b (Occasionally nothing to do) 0 Question 39=c (Always something to do)
Fixed Pay GU1 0 Question 10=a or b (By individual or work) 2 Question 10=c (Fixed pay)
HIGH DEMAND Three or more information sources simultaneously IH1 2 Three or more sources simultaneously (overall assessment, see especially Questions 40, 43, 51-57) 0 Not >2 sources simultaneously (overall assessment, see especially Questions 40, 43, 51-57)
Heterogeneous information IH2 2 Maximally Heterogeneous information Question 38=a, Q. 36-37 >5 tasks OR Q. 51- 57 (many interactions with persons or several machines) 1 Moderately heterogeneous information Question 38=a, Q. 36-37 up to 5 tasks OR Q. 51- 57 (some interactions with persons or machines) 0 Homogeneous information Question 38=b or c, AND Q. 36-37 a few, simple tasks, AND Q. 51- 57 (Limited or minimal interactions with persons or few machines)
Visual Input Primary IH3 2 Visual input sole modality (Questions 36-37=only visual tasks AND Q.49=a AND Q. 52-57 minimal interactions with people) 1 Visual input primary (Questions 36-37=primarily visual tasks / Q.49, Q. 52-57 may have interactions with people) 0 Visual input minor modality (Questions 36-37=few visual tasks)
More than five new signals per minute IH4 Based on Questions 42 and 51-57 0 Question 42=a & 51=yes (controls speed him or herself) OR < 5 new signals/minute (overall assessment, see especially Questions 51-57) 2 Question 42=b or c, 51=no (doesn't control speed) AND > 5 new signals/ minute (overall assessment, see especially Questions 51-57)
Three sensory modalities simultaneously IH5 Based on overall assessment 2 Three modalities simultaneously (see Questions 36-37, q. 40, and 51-57) 0 Not the case (see Questions 36-37, q. 40, and 51-57)
Communication necessary for work IH6 0 Question 49=a (no need for communication with others) 1 Question 49=b (sometimes communication needed) 2 Question 49=c (communication essential part of work)
Complex Decisions/Interrelated Elements CH1 2 Question 44=c, d or e (makes decisions) AND Question 43= b or c (supervisory work - large number of people or various profiles) OR Question 45=clearly complex decisions (many interactions among the data) 1 Question 44= c, d or e (makes decisions) AND Question 43= b or c (supervisory work - few people and single profile) OR Question 45=somewhat complex decisions 0 Question 44=a or b (automatic decisions)AND Question 43=a (No supervisory work)
Complicated Decisions/Many Elements CH2 2 Question 44=c, d or e (makes decisions) AND Question 43= b or c (supervisory work large number of people or various profiles) OR Question 45=clearly complicated decisions (many pieces of data) 1 Question 44= c, d or e (makes decisions) AND Question 43= b or c (supervisory work few people and single profile) OR Question 45=somewhat complicated decisions 0 Question 44=a or b (automatic decisions)AND Question 43=a (No supervisory work)
Decisions affect the work of others CH3 0 Question 43 = a (no supervisory work) 2 Question 43 = b (supervising is a main task) 1 Question 43 = c (sometimes acts as a supervisor)
Rapid Decisions CH4 2 Question 46 = a (frequent) 1 Question 46 = b (occasional) 0 Question 46 = c (no)
Heterogeneous Tasks OH1 2 Question 38=a (Heterogeneous tasks)AND Question 36=3 or more tasks 1 Question 38=a (Heterogeneous tasks)AND Question 36= two or fewer 0 Question 38= b or c (Homogeneous tasks)
Simultaneous Task Performance OH2 2 Question 40= c (3 or more tasks simultaneously, also consider supervisory work q. 43) 1 Question 40=b (occasionally 3 or more tasks, also consider supervisory work q. 43) 0 Question 40=a and no supervising
Complex Tasks OH3 2 Many stepped tasks (see Questions 36 & 37) 1 A few steps in tasks (see Questions 36 & 37) 0 Simple tasks (see Questions 36 & 37)
Rapid Task Execution OH4 0 Question 41 = a (no) 1 Question 41 = b (sometimes) 2 Questions 41= c (vital)
Piece Rate GH1 2 Question 10=a (By individual work) 1 Question 10=b (Group work) 0 Question 10=c (Fixed pay)
Long work hours GH2 2 Question 5-7 (frequently over 48h/week, &/or occasionally over 60h/week) 1 Question 5-7(frequently over 42h/week, &/or occasionally over 48h/week) 0 Question 5-7(rarely over 42h/week)
Two or more jobs GH3 2 Question 7 =yes 0 Question 7=no
Rest breaks GH4 0 Question 8=yes (always at least one break) 2 Question 8=no
Night shift work GH5 0 Question 9= no night shift work) 1 Question 9=a (night shift only) 2 Question 9=b(rotating night shift)
STRICTNESS Strict requirements for signal detection IST 0 Question 26=a (not strict) 1 Question 26=b (somewhat strict) 2 Question 26=c (very strict)
Strict problem solving strategy CS1 0 Question 48=a (possibilities for creativity) 1 Question 48=b (limited freedom in problem-solving) 2 Question 48=c (only 1 correct strategy)
Strictly defined correct decision CS2 2 Question 47=a (only one correct decision) 1 Question 47=b(limited number of correct decisions) 0 Question 47=c (many possible correct decisions, flexible)
Strict evaluation of performance OST 0 Question 11=a (primarily self-evaluation) 1 Question 11=b (some evaluation by others) 2 Question 11=c (strict evaluation by others)
Fixed Posture GS1 0 Question 19=a (mobile) 1 Question 19=b (mainly single posture, but free to move) 2 Question 19=c (fixed body position, constrained motion)
Limited work space GS1 0 Question 20=a (works outside or in a large space) 1 Question 20=b (works in a workshop or small office) 2 Question 20=c (works in a small cabin or other very cramped space)
EXTRINSIC TIME PRESSURE Control of incoming signals IEPT 0 Full control over incoming signals (Question 42=a & Q. 51=controls speed of devices, consider also Q. 52-57) 1 Partial control over incoming signals (Question 42=b, consider also Q. 51-57) 2 No control over incoming signals (Question 42=c, or 51-57 indicate lack of control over incoming signals)
Decisions cannot be postponed CEPT 0 Question 27=a (decisions can be postponed) 1 Question 27=b (sometimes decisions cannot be postponed) 2 Question 27=c (decisions often cannot be postponed)
Control of Task Performance Rate OEPT 0 Question 42=a (full control over rate of task performance) 1 Question 42=b (partial control over rate of task performance) 2 Question 42=c (no control of rate over task performance)
Deadline Pressure GEP1 2 Question 24 =a (frequent) 1 Question 24=b (occasional) 0 Question 24=c (rarely)
Speedup GEP2 2 Question 25=a or c (daily or certain times of every month) 1 Question 25=b or d (weekly but not daily, or certain periods of the year) 0 Question 25=rarely or never
AVERSIVENESS/NOXIOUS EXPOSURES Glare INOX1 2 Question 12 =a, often 1 Question 12=b, occasionally 0 Question 12=c, rarely or never
Noise INOX2 2 Question 13 =a, (likely 90dB or more) 1 Question 13=b, (moderate noise, likely under 90 dB) 0 Question 13=c, (minimal noise exposure)
Isometric lifting ONOX1 2 Question 14=a Over 50 kg. regularly 1 Question 14=b 20-50 kg. 0.5 Question 14=c (up to 20 kg) 0 Question 14=No noteworthy lifting
Vibration exposure ONOX2 2 Question 15 =a, (frequent exposure to vibration, at least 1 hour per day or 7 hours per week) 1 Question 15=a, (some exposure to vibration, at least once per week, less than 7 hours per week) 0 Question 15=b, (minimal vibration exposure, less than 1 hour per week)
Heat Exposure GNOX1 0 Question 16=a (not over 30 degrees C) 1 Question 16=b (30 to 40 degrees C) 2 Question 16=c (over 40 degrees C)
Cold Exposure GNOX2 0 Question 17=a (at least 15 degrees C) 1 Question 17=b (10 -15 degrees C) 2 Question 17=c (under 10 degrees C)
Exposure to fumes, gases &/or dusts GNOX3 0 Question 18=a (No) 1 Question 18=b (sometimes) 2 Question 18=c (feels heavy exposure)
AVOIDANCE (SYMBOLIC AVERSIVENESS/DISASTER POTENTIAL) Need for sustained alertness to avoid serious consequences IAVOI1 Do an overall assessment 2 Vigilance is primary task (e.g. security guard, police, air traffic controller) 1 Question 21=a, b, c or d, or sustained alertness required but not primary task 0 Question 21=e and some controlled lapses of attention can be tolerated
Serious consequences of wrong decisions CAVOIT 0 Question 28=a (can correct errors) 1 Question 28=b (potential material or other serious damage from error) 2 Question 28=c (potential fatality from error)
Hazardous Task Performance OAVOIT 2 Question 21=a, b, c or d (dangerous work) 1 Performs tasks with some risk e.g. welding, driving, drilling (see q. 36-37, and do overall assessment) 0 Question 21=e and some controlled lapses of attention can be tolerated
Experienced Accident or Injury at Work GAVOI1 0 Question 22=a (none) 1 Question 22=b (minor) 2 Question 22=c (serious)
Witnessed Accident or Injury at Work GAVOI2 2 Question 23 = a (witnessed fatal accident at work) 1 Question 23 = b (witnessed serious accident at work) 0.5 Question 23 = c (heard about but never witnessed a serious accident at work) 0 Question 23= d (never heard about or witnessed a serious accident at work)
CONFLICT/UNCERTAINTY Signal/noise conflict ICNFL1 0 Question 29=a (clear signals) (consider also Q. 36-37) 1 Question 29=b (some signal/noise conflict) (consider also Q. 36-37) 2 Question 29=c (frequent signal/noise conflict) (consider also Q. 36-37)
Signal/signal conflict ICNFL2 0 Question 29=a (clear signals) (consider also Q. 36-37) 1 Question 29=b (some signal/signal conflict) (consider also Q. 36-37) 2 Question 29=c (frequent signal/signal conflict) (consider also Q. 36-37)
Missing information needed for decision-making CCNFL1 2 Question 30=a (information frequently missing) 1 Question 30=b (information sometimes missing) 0 Question 30=c (rarely or never)
Contradictory information CCNFL2 2 Question 31=a (frequently) 1 Question 31=b (sometimes) 0 Question 31=c (rarely or never)
Unforeseeable events require new plan CCNFL3 2 Question 32=a (frequently) 1 Question 32=b (sometimes) 0 Question 32=c (rarely or never)
Conflicting demands in time and space OCNFL1 0 Question 33=a (no) 1 Question 33=b (occasionally) 2 Question 33=c (frequently)
External conditions hamper task performance OCNFL2 2 Question 34=a 1 Question 34=b 0 Question 34=c
Emotionally-charges work atmosphere GCNFL1 0 Question 35=a (no) 1 Question 35=b (somewhat) 2 Question 35=c (highly emotionally-charged)