Survey

A Personal Work-Life Survey

Self

Scale of Importance
1 Not Important, 2 Slightly Important, 3 Quite Important, 4 Extremely Important
Scale of Agreement
1 Stronlgy Disagree, 2 Disagree, 3 Neutral, 4 Agree, 5 Strongly Agree

I devote sufficient effort to my physical well-being.
Importance 1 2 3 4  
Agreement 1 2 3 4 5
Total =
I have a personal hobby that provides me with adequate relaxation.
Importance 1 2 3 4  
Agreement 1 2 3 4 5
Total =
I actively embrace personal growth opportunities.
Importance 1 2 3 4  
Agreement 1 2 3 4 5
Total =
I actively pracitce a religion and/or spiritual discipline.
Importance 1 2 3 4  
Agreement 1 2 3 4 5
Total =
Overall, I feel integrated and balanced in terms of body, mind and spirit.
Importance 1 2 3 4  
Agreement 1 2 3 4 5
Total =
SELF Subtotal =

Family

Scale of Importance
1 Not Important, 2 Slightly Important, 3 Quite Important, 4 Extremely Important
Scale of Agreement
1 Stronlgy Disagree, 2 Disagree, 3 Neutral, 4 Agree, 5 Strongly Agree

I experience quality relationship and communication with my spouse, partner, or significant other.
Importance 1 2 3 4  
Agreement 1 2 3 4 5
Total =
I experience quality relationship and communication with other significant family members, (children, parents, in-laws, cousins, etc)
Importance 1 2 3 4  
Agreement 1 2 3 4 5
Total =
I devote sufficent quality time with my family to achieve balance with my work responsibilities.
Importance 1 2 3 4  
Agreement 1 2 3 4 5
Total =
I proactively resolve family conflicts, problems, or crises as they occur.
Importance 1 2 3 4  
Agreement 1 2 3 4 5
Total =
Overall, I am statisfied with both the time devoted to and the quality of my family (or interpersonal) relationships.
Importance 1 2 3 4  
Agreement 1 2 3 4 5
Total =
FAMILY Subtotal =

Work

Scale of Importance
1 Not Important, 2 Slightly Important, 3 Quite Important, 4 Extremely Important
Scale of Agreement
1 Stronlgy Disagree, 2 Disagree, 3 Neutral, 4 Agree, 5 Strongly Agree

My work is personally meaningful to me.
Importance 1 2 3 4  
Agreement 1 2 3 4 5
Total =
I exercise maximum self-management in the performance of my job.
Importance 1 2 3 4  
Agreement 1 2 3 4 5
Total =
I am very competent for the work that I do.
Importance 1 2 3 4  
Agreement 1 2 3 4 5
Total =
I am creative and innovative as required by my work.
Importance 1 2 3 4  
Agreement 1 2 3 4 5
Total =
Overall, I am clear about my short and long-term career goals and my plan to achieve them.
Importance 1 2 3 4  
Agreement 1 2 3 4 5
Total =
WORK Subtotal =

Service

Scale of Importance
1 Not Important, 2 Slightly Important, 3 Quite Important, 4 Extremely Important
Scale of Agreement
1 Stronlgy Disagree, 2 Disagree, 3 Neutral, 4 Agree, 5 Strongly Agree

I am aware of how i would most like to contribute to society or others, e.g. money, time, support, etc
Importance 1 2 3 4  
Agreement 1 2 3 4 5
Total =
I devote sufficient time in service to others, e.g. community, religious, recreational, support, etc.
Importance 1 2 3 4  
Agreement 1 2 3 4 5
Total =
I feel I make a difference in the lives of others.
Importance 1 2 3 4  
Agreement 1 2 3 4 5
Total =
I contribute to societal organizations in proportion to my own monetary resources, e.g. tithing contribution, etc.
Importance 1 2 3 4  
Agreement 1 2 3 4 5
Total =
I feel a natural desire to contribute to the welfare and well-being of others.
Importance 1 2 3 4  
Agreement 1 2 3 4 5
Total =
SERVICE Subtotal =

Personal Info

Name
Email
Age
Gender
Marital Status
Ethinicity
Religion
Nationality
Organization