Safety Self Observation
CHECK LIST STRESS
WORK PLACE ……………………………………………………………………..
DATE ……………………………………
A.BEHAVIOURS (Circle a number for each question that best reflects where you feel you have been over the last fortnight.)
1. MENTAL FUNCTIONING
0
1
2
3
4
5
Anxious/depressed > relaxed/calm
2. CONFIDENCE IN LIFE AND WORK
0
1
2
3
4
5
Total lack of confidence > very confident
3. RELATIONSHIP AT WORK
0
1
2
3
4
5
Total breakdown of relationships > Harmonious/positive
4. PHYSIOLOGICAL
0
1
2
3
4
5
Poor health and sleep > excellent health
B. JOB CONTENT AND CONTEXT (Circle a number for each question that best reflects where you feel you have been over the last fortnight.)
1. COMMUNICATION IN THE WORKPLACE
0
1
2
3
4
5
Bad > Barely > Fair > Good > Very Good > Excellent
2. SUPPORT IN THE WORK PLACE
0
1
2
3
4
5
Bad > Barely > Fair > Good > Very Good > Excellent
3. ROLE CLARITY IN THE WORK PLACE
0
1
2
3
4
5
Bad > Barely > Fair > Good > Very Good > Excellent
4. RECOGNITION/ REWARD FOR WORK WELL DONE
0
1
2
3
4
5
Bad > Barely > Fair > Good > Very Good > Excellent
5. TEAM WORK AND INVOLVEMENT IN PROJECTS TOGETHER
0
1
2
3
4
5
Bad > Barely > Fair > Good > Very Good > Excellent
6. WORKLOAD LEVEL
0
1
2
3
4
5
Bad/too high > Barely > Fair > Good > Very Good > Excellent
7. HOURS WORKED PER WEEK
0
1
2
3
4
5
80+ 70+ 60+ 50+ 45 40
WORK OUT YOUR TOTAL SCORES
SECTION A = ………………………./20
Scores under ten mean that stress is starting to hit you hard. Discuss with HR, your manager or the EAP counselor, but seek help now!
SECTION B = …………………/35
Scores under 20 indicate some significant problems in your section.
Pass this completed form in to your ………… for their report.
Do not place your name on this form unless you wish to personally approach a manager or HR team member to seek assistance for the specific things this form uncovers for you.
THIS FORM MAY ASSIST WORK PLACES KEEPING A CLOSE EYE ON STRESS RELATED PROBLEMS WITHIN THE WORK PLACE IN ACCORDANCE WITH THE HSE ACT CHANGES MAY 2003.
© DR JOHN C MCEWAN 14 AUGUST 2004