PART I

GENERAL INFORMATION

Occupation: _____________________________________________________________
How long have you worked for this company? _________________________________
What previous positions have you held with the company? ________________________
________________________________________________________________________
________________________________________________________________________
What is your job title? _____________________________________________________
How long have you held your current position? _________________________________
Briefly describe your work responsibilities (as you would on a resume):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
PART II
RATING YOUR JOB SATISFACTION

1
Strongly
disagree

2
Dis agree

3
neutral

4
agree

5
extremely
agreed

Using the scale shown above, rate your level of satisfaction with the following aspects of
your job.
GENERAL WORKING CONDITIONS

_____ Hours worked each week

_____ Flexibility in scheduling
_____ Location of work
_____ Amount of paid vacation time/sick leave offered
PAY AND PROMOTION POTENTIAL

_____ Salary
_____ Opportunities for Promotion
_____ Benefits (Health insurance, life insurance, etc.)

_____ Job Security

_____ Recognition for work accomplished
WORK RELATIONSHIPS

_____ Relationships with your co-workers

_____ Relationship(s) with your supervisor(s)
_____ Relationships with your subordinates (if applicable)
USE OF SKILLS AND ABILITIES

_____ Opportunity to utilize your skills and talents

_____ Opportunity to learn new skills
_____ Support for additional training and education
WORK ACTIVITIES

_____ Variety of job responsibilities

_____ Degree of independence associated with your work roles
_____ Adequate opportunity for periodic changes in duties
PART 3: ORGANIZATIONAL POLITICS:
One group always gets their way
1: strongly disagree 2: disagree 3: neutral

4: agreed 5: strongly agreed

Influential group no one crosses

1: strongly disagree 2: disagree

3: neutral

4: agreed 5: strongly agreed

Policy changes help only a few

1: strongly disagree 2: disagree

3: neutral

4: agreed 5: strongly agreed

Some build themselves up by tearing others down

1: strongly disagree 2: disagree 3: neutral 4: agreed 5: strongly agreed
Favoritism not merit gets people ahead
1: strongly disagree 2: disagree 3: neutral

4: agreed 5: strongly agreed

Dont speak up for fear to retaliation

1: strongly disagree 2: disagree 3: neutral

4: agreed 5: strongly agreed

Promotions go to top performers

1: strongly disagree 2: disagree 3: neutral

4: agreed 5: strongly agreed

Rewards come to hard workers

1: strongly disagree 2: disagree

3: neutral

4: agreed 5: strongly agreed

Encouraged to speak out

1: strongly disagree 2: disagree

3: neutral

4: agreed 5: strongly agreed

Sefer to agree then to say what you think is right

1: strongly disagree 2: disagree 3: neutral 4: agreed 5: strongly agreed
4: job performance:
You consistently meet the formal performance requirements of his/her job
1: strongly disagree 2: disagree 3: neutral 4: agreed 5: strongly agreed
You fulfil all the responsibilities specified in his/her job description
1: strongly disagree 2: disagree 3: neutral 4: agreed 5: strongly agreed
You performs tasks that are expexted of him/her
1: strongly disagree 2: disagree 3: neutral 4: agreed 5: strongly agreed