WEB PAGE FOR DR JOHN C MCEWAN - DR STRESS
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 Harmonious
Of relationships 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