Personal Information

Name* Emp.# *
Designation Function/Dept
I am part of
Technical/Produc
tion function
Yes/No I am part of
Operations/Sup
port function
Yes/No
Total rs of
e!perience
"rs of
e!perience in
current Org.
Organisation
Name
O#ce/$or%
location &cit'
*not mandator
Work-Life related
Instruction: Please mark () against the right answer
(. )o* man das in a *ee% do ou normall *or%+
a' ,ess than - das
.' - das
c' / das
d' 0 das
1. )o* man hours in a da do ou normall *or%+
a' 023 hours
.' 324 hours
c' 42(5 hours
d' (52(1 hours
e' 6ore than (1 hours
7. )o* man hours a da do ou spend tra8elling to *or%+
a' ,ess than half an hour
.' Nearl one hour
c' Nearl t*o hours
d' 6ore than t*o hours
9. Do ou *or% in shifts+
a' :eneral shift/da shift
.' Night shift
c' ;lternati8e &morning or e8ening shift'
-. ;re ou married+
a' "es
.' No
/. If es< is our spouse emploed+
a' "es
.' No
0. Do ou ha8e children+
a' "es< no. of children============.
.' No
3. >eing an emploed man/*oman *ho is helping ou to ta%e care of
our children+
a' Spouse
.' In2la*s
c' Parents
d' Ser8ants
e' ?r@che/da care center
f' Not applica.le
4. )o* man hours in a da do ou spend *ith our child/children+
a' ,ess than 1 hours
.' 127 hours
c' 729 hours
d' 92- hours
e' 6ore than - hours
f' Not applica.le
(5. Do ou regularl meet our child/children teachers to %no*
ho* our child is progressing+
a' Once in a *ee%
.' Once in t*o *ee%s
c' Once in month
d' Once in / months
e' Once in a ear
f' Not applica.le
((. Do ou ta%e care of+
a' Older people
.' Dependent adults
c' ;dults *ith disa.ilities
d' ?hildren *ith disa.ilities
e' None
(1. If es< ho* man hours do ou spend *ith them+
a' ,ess than 1 hours
.' 127 hours
c' 729 hours
d' 92- hours
e' 6ore than - hours
(7. )o* do ou feel a.out the amount of time ou spend at *or%+
a' Aer unhapp
.' Bnhapp
c' IndiCerent
d' )app
e' Aer happ
(9. Do you ever miss out any quality time with your family or your friends
because of pressure of work?
a' Ne8er
.' Darel
c' Sometimes
d' Often
e' ;l*as
(- Do ou *or% late hours
at o#ce e8er da+
(
Ne8er
1
Darel
7
Sometim
es
9
Often
-
;l*a
s
(/ Do ou ta%e our *or%
at home+
(
Ne8er
1
Darel
7
Sometim
es
9
Often
-
;l*a
s
(0 Do ou feel stressed
a.out the amount of
time ou spend at
*or%+
(
Ne8er
1
Darel
7
Sometim
es
9
Often
-
;l*a
s
(3 Do ou feel stressed as
ou need to tra8el
more to *or%+
(
Ne8er
1
Darel
7
Sometim
es
9
Often
-
;l*a
s
(4 Do ou feel stressed
*hen ou thin% a.out
*or%+
(
Ne8er
1
Darel
7
Sometim
es
9
Often
-
;l*a
s
15 Do ou ta%e lunch
.rea% *hich does not
e8en last for more than
75 minutes+
(
Ne8er
1
Darel
7
Sometim
es
9
Often
-
;l*a
s
1( Do ou miss out on
Eualit time *ith our
famil and friends
.ecause of *or%
pressure+
(
Ne8er
1
Darel
7
Sometim
es
9
Often
-
;l*a
s
11 Do ou thin% *or% is
ha8ing negati8e eCect
on our personal life+
(
Ne8er
1
Darel
7
Sometim
es
9
Often
-
;l*a
s
17 Do ou thin% that ou
do not get enough time
for ourself+
(
Ne8er
1
Darel
7
Sometim
es
9
Often
-
;l*a
s
19 Do ou feel upset
.ecause of *hat is
happening at *or%
(
Ne8er
1
Darel
7
Sometim
es
9
Often
-
;l*a
s
1- Do ou often loose
our temper at *or%+
(
Ne8er
1
Darel
7
Sometim
es
9
Often
-
;l*a
s
1/ Do ou feel tired or
depressed .ecause of
*or%+
(
Ne8er
1
Darel
7
Sometim
es
9
Often
-
;l*a
s
1/' )o* do ou manage stress arising from our *or%+
f' "oga
g' 6editation
h' Entertainment
i' Dance
F' 6usic
%' Others< specif=========.
10' Does our compan ha8e a separate polic for *or%2life .alance+
a' "es
.' No
c' Not a*are
13' If es< *hat are the pro8isions under the polic+
a' Fle!i.le starting time
.' Fle!i.le ending time
c' Fle!i.le hours in general
d' )olidas/ paid time2oC
e' Go. sharing
f' ?areer .rea%/sa..aticals
g' Others< specif========
14' Do ou personall feel an of the follo*ing *ill help ou to .alance
our *or% life+
a' Fle!i.le starting hours
.' Fle!i.le Hnishing time
c' Fle!i.le hours< in general
d' holidas/paid time oCs
e' Go. sharing
f' ?areer .rea%/sa..aticals
g' time2oC for famil engagements/e8ents
h' Others< specif=========
75' Does our organiIation pro8ide ou *ith follo*ing additional *or%
pro8isions+
a' Telephone for personal use
.' ?ounselling ser8ices for emploees
c' )ealth programs
d' Parenting or famil support programs
e' E!ercise facilities
f' Delocation facilities and choices
g' Transportation
h' Others< specif==============.
7(' Does our organiIation encourage the in8ol8ement of our famil
mem.ers in *or%2 achie8ement re*ard functions+
a' "es
.' No
71' Does our organiIation ha8e social functions at times suita.le for
families+
a' "es
.' No
77' Do an of the follo*ing hinder ou in .alancing our *or% and famil
commitments+
,ong *or%ing hour
?ompulsor o8ertime
$or% pressure
Shift *or%
6eetings/training after o#ce hours
Others< specif=================
79' Do an of the follo*ing help ou .alance our *or% and famil
commitments+
a' $or%ing from home
.' Technolog li%e laptops/APN/Internet/cell phones
c' >eing a.le to .ring ?hildren to *or% on occasions
d' Support from colleagues at *or%
e' Support from famil mem.ers
f' Others< specif===========.
7-' Do an of the follo*ing hinder ou in .alancing our *or% and famil
commitments+
a' Technolog li%e laptops/APN/Internet/cell phones
.' FreEuentl tra8elling a*a from home
c' Negati8e attitude of peers and colleagues at *or% place
d' Negati8e attitude of super8isors
e' Negati8e attitude of famil mem.ers
f' Others< specif===========
g' ;ll a.o8e
h' None
7-' Do ou suCer from an stress2related disease+
a' )pertension
.' O.esit
c' Dia.etes
d' FreEuent headaches
e' None
f' Others< specif======.
7/' Do ou ta%e special initiati8es to manage our diet+
a' "es
.' No
70' $hat is our preference for food+
a' ?arring home made food
.' Dieting on 8egeta.les and fruits
c' ?hoosing less caloriHc food
d' ?hoosing organic food
e' Food from the organiIations cafeteria
f' Spic/Gun% food
g' Others< specif==========.
73' )o* often *ill ou ha8e refreshment drin%s/snac%s in a da+
a' None
.' Once
c' T*ice
d' Thrice
e' 6ore than three times
74' Do ou spend time for *or%ing out+
a' "es
.' No
95' If es< ho* man hours+
a' less than half an hour
.' half an hour
c' half an hour to one hour
d' more than ( hour
9(' $here do ou usuall prefer to do our *or%outs+
a' In our organiIations health centers
.' Desidence
c' Near. :m
d' $al%ing
e' Others< specif=============.
9(' Do ou feel *or%2life .alance polic in the organiIation should .e
customiIed to indi8idual needs+
a' Strongl agree
.' ;gree
c' IndiCerent
d' Disagree
e' Strongl disagree
91' $hich of the follo*ing *ill .e indi8idual .eneHts due to enhanced
*or%2life .alance+
l' 6ore 8alue and .alance in our life
m' Bnderstanding our .est *or% life .alance
n' Increased producti8it
o' >etter relationship .oth on and oC the Fo.
p' Deduced Stress
E' ;ll the a.o8e
r' None
97' Do ou thin% that if emploees ha8e good *or%2life .alance the
organiIation *ill .e more eCecti8e and successful+
a' "es
.' No
99' If es< *hich of the follo*ing *ill .e organisationJs .eneHts due to
good *or%2life .alance of the emploees+
s' 6easured increase in producti8it< accounta.ilit<
commitment
t' >etter team*or% and communication
u' Impro8ed morale
8' ,ess negati8e organiIational stress
*' ;ll the a.o8e
!' None