Tool
MODEL QUESTIONNAIRE

Here's a Model Questionnaire you can adapt to survey your workers' health, wellbeing and productivity. It's based on a form prepared by the Mayo Clinic and incorporates recommendations from the Manitoba Model.

Work Productivity & Activity Impairment Questionnaire

Instructions: Please provide honest answers to these questions. Your identity will remain confidential so you can speak candidly. When we refer to “health problems,” we mean any physical or emotional problems or symptoms you experience.

1. How heavy do you consider your current workload?
   1 (Light) 2 (Moderate) 3 (Fair) 4 (Heavy) 5 (Unreasonable)
2. How challenging and interesting do you consider your job to be?
   1 (Unchallenging) 2 3 4 5 (Extremely challenging)
3. What level of stress do you experience at work?
   1 (Light) 2 (Moderate) 3 (Fair) 4 (Heavy) 5 (Unreasonable)
4. What accounts for the stress you feel?
   
   __ Amount of work
   
   __ Supervisor
   
   __ Nature of work
   
   __ Relationship with co-workers
   __ Personal problems
   __ Other (please describe)
   ____________________________________________________________________________________________________________________________________
5. During the past two weeks, how many hours did you miss from work because of health problems? (Please include hours missed as a result of sick days, leaving early, coming late) ____________________________________________________________________________________________________________________________________
6. During the past two weeks, how many hours did you miss from work because of personal problems? (Please include hours missed as a result of sick days, leaving early, coming late) ____________________________________________________________________________________________________________________________________
7. Please rate your productivity on the days you did show up for work. (Please list the number of hours you believe were spent unproductively at work because of health problems) ____________________________________________________________________________________________________________________________________
8. Please list the number of hours you believe were spent unproductively at work because you were distracted by stress or personal problems. ____________________________________________________________________________________________________________________________________
9. Please describe any other way that health ailments, fatigue, mental stress or personal problems have affected your work in the past two weeks. ____________________________________________________________________________________________________________________________________

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