Work Organization Predictors of Depression in Women (Participant Questionnaire)

COMPANY PROGRAMS AND POLICIES

Appendix C

Copy of Participant Questionnaires

Form Approved

OMB No. 0920-XXXX

Exp. Date __________

NIOSH Work Environment Survey

National Institute for Occupational Safety and Health

Division of Applied Research and Technology

Cincinnati, Ohio 45226

Public reporting burden of this collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0630)

Does your employer have the following programs or policies at work?

Flextime (e.g., allows you to choose your own starting and quitting times within a range of hours)?	Y	N
Job sharing – where two or more part-time employees share the duties of one full-time job?	Y	N
Working from home?	Y	N
Diversity awareness programs?	Y	N
Conflict resolution programs/seminars?	Y	N
A Mentoring program?	Y	N
Paid maternity leave?	Y	N
On-site or off-site child care?	Y	N
Counseling services?	Y	N
Stress reduction programs?	Y	N
A Medical plan?	Y	N
Benefits for students such as tuition reimbursement, or flexible work schedules?	Y	N

Has your employer offered you training to enhance your job skills?	Y	N
Did you take the training?	Y	N
Does your employer have a written policy on discrimination?	Y	N
Does your employer have official procedures for dealing with discrimination?	Y	N
Does your employer have a written policy on sexual harassment?	Y	N
Does your employer have official procedures for dealing with sexual or other forms of harassment?	Y	N

Rate the degree to which you agree or disagree with each of the following statements. Please use the following scale for questions 19-21.

1 Strongly Disagree

2 Disagree

3 Neither Agree Nor Disagree

4 Agree

5 Strongly Agree

The organization that I work for takes sexual harassment complaints very seriously.	1	2	3	4	5
In this company, you can "get off the hook" if you know who to talk to when a sexual harassment complaint is filed against you.	1	2	3	4	5
Persons found guilty of sexual harassment in my company would probably be disciplined (e.g., be suspended, lose promotional opportunities, or be fired).	1	2	3	4	5

Please use the following scale to answer questions 1 – 14.

1 Strongly Disagree

2 Disagree

3 Neither Agree Nor Disagree

4 Agree

5 Strongly Agree

I know exactly what is expected of me.	1	2	3	4	5
I receive incompatible requests from two or more people.	1	2	3	4	5
The members of my group are supportive of each other's ideas.	1	2	3	4	5
There is cooperation between my group and other groups.	1	2	3	4	5
There is honest communication.	1	2	3	4	5
There is trust between my company and me.	1	2	3	4	5
My company treats its employees fairly.	1	2	3	4	5
My company is interested in the welfare of its employees.	1	2	3	4	5

My job requires me to work very hard.	1	2	3	4	5
My job leaves me with little time to get things done at work.	1	2	3	4	5
There is often a great deal to be done at work.	1	2	3	4	5
My job fits my skills.	1	2	3	4	5
My work is challenging.	1	2	3	4	5
I can learn new things on my job.	1	2	3	4	5

Please use the following scale to answer questions 15 - 20.

1 None

2 A Little

3 Some

4 A Lot

5 A Great Deal

How much influence do you have over…

The variety of tasks you perform?	1	2	3	4	5
The availability of supplies and equipment you need to do your work?	1	2	3	4	5
The order in which you perform tasks at work?	1	2	3	4	5
The amount of work you do?	1	2	3	4	5

How much do you participate with others in helping set the way things are done on your job?	1	2	3	4	5
How much are employees of different gender, racial/ethnic, age, or physical capability groups included in decision-making on the job?	1	2	3	4	5

How certain are you of the opportunities for promotion and advancement in the next few years?
1 Not at all Certain	2 Not very Certain	3 Somewhat Certain	4 Fairly Certain	5 Very Certain

Please use the following scale to answer questions 22 – 23.

1 Not at all

2 A little

3 Somewhat

4 Very Much

How much does each of these people go out of their way to do things to make your work life easier for you?
Your immediate supervisor (boss)	1	2	3	4
Other people at work	1	2	3	4
Your spouse, friends, and relatives	1	2	3	4
How much can each of these people be relied on when things get tough at work?
Your immediate supervisor (boss)	1	2	3	4
Other people at work	1	2	3	4
Your spouse, friends, and relatives	1	2	3	4

On an average workday…

How many hours do you spend caring for and doing things with your children?
How many hours do you spend on household chores?
How many hours do you have to relax or pursue activities that you enjoy?

During an average workweek…

How many hours do you spend caring for and doing things with an elderly relative or friend?
How many days do you have to work overtime with no notice?
How many days do you bring work home?

In the past month, how many nights have you spent away from home for business-related travel?

Rate the degree to which you agree or disagree with each of the following statements. Please use the following scale for questions 8-15.

1 Strongly Disagree

2 Disagree

3 Neither Agree Nor Disagree

4 Agree

5 Strongly Agree

High visibility assignments or tasks are assigned without regard to gender (that is, similarly qualified men and women would be equally likely to receive this assignment).	1	2	3	4	5
People at work seem more comfortable socializing with others of the same sex rather than with those of the opposite sex.	1	2	3	4	5
In this office, men are not as comfortable serving as a mentor to a woman as they are to a man.	1	2	3	4	5
If an employee in this office told a joke that was degrading to women, someone would be likely to criticize them.	1	2	3	4	5
If an employee in this office told a joke that was degrading to an ethnic or racial group, someone would be likely to criticize them.	1	2	3	4	5
Promotions are given in this company without regard to gender (that is, men and women are treated equally if they are equally qualified).	1	2	3	4	5
In general, supervisors in this company are understanding when personal or family obligations occasionally take an employee away from work.	1	2	3	4	5
In this office, people pay just as much attention when women speak as when men speak.	1	2	3	4	5

Please use the following scale to answer questions 1 – 11.

1 Never

2 Occasionally

3 Sometimes

4 Often

5 Almost Always

During the past week, how often did you:

Find you have forgotten to call someone or respond to a request?	1	2	3	4	5
Have a co-worker redo something you had completed?	1	2	3	4	5
Work more slowly or take longer to complete tasks than expected?	1	2	3	4	5
Have trouble organizing work or setting priorities?	1	2	3	4	5
Find it difficult to concentrate on the task at hand?	1	2	3	4	5
Arrive at work late or leave work early?	1	2	3	4	5
Take longer lunch hours or coffee breaks?	1	2	3	4	5
Find yourself daydreaming, worrying, or staring into space when you should be working?	1	2	3	4	5
Have your boss/coworkers remind you to do things?	1	2	3	4	5
Avoid interaction with co-workers, clients, vendors or supervisors?	1	2	3	4	5
Not do work at times when you would be expected to be working?	1	2	3	4	5

Please use the following scale to answer questions 12 - 19.

1 Never

2 Occasionally

3 Sometimes

4 Often

5 Always

How often does your family or personal life keep you from getting work done on time at your job?	1	2	3	4	5
How often does your family or personal life keep you from doing as good a job as you could at work?	1	2	3	4	5
How often does your family or personal life drain you of the energy you need to do your job?	1	2	3	4	5
How often does your family or personal life keep you from concentrating on your job?	1	2	3	4	5

How often do you not have enough time for yourself because of your job?	1	2	3	4	5
How often do you not have enough time for your family or other important people in your life because of your job?	1	2	3	4	5
How often do you not have the energy to do things with your family or other important people in your life because of your job?	1	2	3	4	5
How often are you not able to get everything done at home each day because of your job?	1	2	3	4	5

Please use the following scale to answer questions 20-25.

1 Strongly Disagree

2 Disagree

3 Neither Agree Nor Disagree

4 Agree

5 Strongly Agree

I take pride in doing my job as well as I can.											1	2	3	4	5
I feel unhappy when my work is not up to my usual standard.											1	2	3	4	5
I like to look back on the day's work with a sense of a job well done.											1	2	3	4	5
I sometimes feel like leaving my company.											1	2	3	4	5
I feel myself to be part of my company.											1	2	3	4	5
In my work, I like to think that I am making some effort, not just for myself but for my company as well.											1	2	3	4	5
All in all, how satisfied would you say you are with your job?
1 Not at all satisfied		2 Not very satisfied		3 Somewhat satisfied				4 Very satisfied
Would you say that in general your health is:				1 Excellent		2 Very good	3 Good		4 Fair				5 Poor
During the last month, would you say that you experienced:
1 A lot of stress		2 A moderate amount of stress		3 Relatively little stress				4 Almost no stress at all
How often do you have trouble getting to sleep, waking up in the middle of the night, or waking up early in the morning?
1 Never	2 A few times per year		3 A few times per month		4 A few times per week					5 Daily

Please indicate whether the following events have happened to you within the past year. These events may have occurred to someone else but we’re interested in what has happened to you within the past year.

Had trouble with a boss (not including sexual harassment)	Y	N
Relations with spouse or partner changed for the worse	Y	N
Separated from or divorced your partner	Y	N
Death of a spouse, partner, or child	Y	N
Death of an other extended family member or close friend	Y	N
You or your partner recently became pregnant	Y	N
You or your partner gave birth to or adopted a child	Y	N
Moved to a different residence or neighborhood	Y	N
Physically assaulted or attacked	Y	N
Involved in a lawsuit, arrested, convicted or found guilty of a crime	Y	N
Suffered a financial loss or loss of property	Y	N
Been seriously ill, seriously injured, or had an illness get worse?	Y	N
During the past 12 months, were there other events that caused disruption in your life that were not included in the above list? You may specify up to two additional events: _________________________ _________________________	Y	N

Please indicate the degree to which you agree with the following statements, using the following scale:

1 Completely Disagree

2 Agree a Little

3 Moderately Agree

4 Strongly Agree

5 Completely Agree

It bothers me when people try to direct my behavior or activities.	1	2	3	4	5
It is very important that I feel free to get up and go whenever I want.	1	2	3	4	5
I prefer to make my own plans, so that I am not controlled by others.	1	2	3	4	5
In relationships, people often are too demanding of each other.	1	2	3	4	5
I don’t like people to invade my privacy.	1	2	3	4	5
I am concerned that if people knew my faults or weaknesses they would not like me.	1	2	3	4	5
If a friend has not called for awhile, I get worried that he or she has forgotten me.	1	2	3	4	5
If somebody criticizes my appearance, I feel I am not attractive to other people.	1	2	3	4	5
I am uneasy when I cannot tell whether or not someone I’ve met likes me.	1	2	3	4	5
When I am with other people, I look for signs whether or not they like being with me.	1	2	3	4	5

During the past 30 days, other than your regular job, did you participate in any physical activities or exercise (i.e., running, calisthenics, golf, gardening, or walking for exercise)?				Y	N
Do you currently smoke cigarettes:	1 every day	2 some days	3 not at all

Are you currently diagnosed with any of the following conditions?

Anxiety	Y	N
Cancer	Y	N
Cardiovascular or heart disease	Y	N
Depression	Y	N
Diabetes	Y	N
HIV / AIDS	Y	N
Hypothyroidism	Y	N
Kidney disease	Y	N
Lupus	Y	N
Multiple Sclerosis	Y	N
Are you currently taking any of the following types of prescription medications?
Antidepressants	Y	N
Anti-anxiety medications	Y	N
Other mood-altering medications	Y	N
Are you currently taking any of the following types of vitamins or herbal supplements?
Multivitamin	Y	N
Kava kava	Y	N
SAMe	Y	N
St. John’s Wort	Y	N
Valerian	Y	N
Do you currently use (within the last two weeks) any other substances such as:
Marijuana?	Y	N
Barbiturates?	Y	N
Sedatives or tranquilizers?	Y	N
Cocaine or crack stimulants?	Y	N
Hallucinogens?	Y	N
Opiates?	Y	N

Please use the following scale to answer questions 1 – 10.

1 Strongly Disagree

2 Disagree

3 Neither Agree Nor Disagree

4 Agree

5 Strongly Agree

On the whole, I am satisfied with myself.	1	2	3	4	5
I feel I do not have much to be proud of.	1	2	3	4	5
I certainly feel useless at times.	1	2	3	4	5
I feel that I am a person of worth, at least on an equal basis with others.	1	2	3	4	5
I feel that I have a number of good qualities.	1	2	3	4	5
All in all, I am inclined to feel that I am a failure.	1	2	3	4	5
I wish I could have more respect for myself.	1	2	3	4	5
I am able to do things as well as most other people.	1	2	3	4	5
At times I think I am no good at all.	1	2	3	4	5
I take a positive attitude toward myself.	1	2	3	4	5

Have any of your BLOOD RELATIVES ever suffered from depression? (A relative would be considered depressed if they felt so low for a period of at least two weeks that they hardly ate or slept or couldn’t do their work or whatever they usually do. A BLOOD RELATIVE is a biological relative, such as parents, siblings and children. A blood relative does not include relatives that are related to you by marriage (e.g., spouse, stepchildren) or adoption (e.g., adoptive parents).	Y	N
In your entire life, have you ever had a time, lasting at least 2 weeks, when you didn’t care about things that you usually cared about, or when you didn’t enjoy the things you usually enjoyed?	Y	N
Prior to the age of 12, did you experience a major trauma (e.g., natural disaster, death of a parent, abuse in the home)?	Y	N
Are you currently attending counseling (like individual, group, couples, or family counseling)?	Y	N

Have you experienced unequal treatment or discrimination at work based on your:
a.) Age?	Y	N
b.) Sex?	Y	N
c.) Race or National Origin?	Y	N
d.) Other (e.g., religion, disability, sexual orientation, etc.)?	Y	N

Using the following scale, indicate how frequently you have experienced the following at work:

1 Never

2 A few times per year

3 A few times per month

4 A few times per week

5 Daily

Sexual harassment includes things like the way coworkers of the opposite sex look at you, talk down to you, or remarks they make to you or each other because of your gender. At your current job, how frequently have you experienced this form of sexual harassment?	1	2	3	4	5
Unwanted sexual attention includes touching in a way that makes you feel uncomfortable, or unwanted, repeated requests for dates or attempts to establish a sexual relationship. At your current job, how frequently have you experienced unwanted sexual attention?	1	2	3	4	5
Sexual coercion includes being bribed, threatened, or made afraid of poor treatment if you don’t cooperate with someone’s sexual requests. At your current job, how frequently have you experienced sexual coercion?	1	2	3	4	5
You may have observed others being sexually harassed by hearing sexual comments made about them, or observing them receive unwanted sexual attention, or being sexually coerced. At your current job, how frequently have you observed others being sexually harassed?	1	2	3	4	5

The following two questions ask about alcohol consumption. For these questions, a drink of alcohol is 1 can or bottle of beer, 1 glass of wine, 1 can or bottle of wine cooler, 1 cocktail or 1 shot of liquor.

How often do you have a drink containing alcohol?
1 Never		2 Monthly or less		3 Two to four times a month		4 Two to three times a week		5 Four or more times a week
How many drinks containing alcohol do you have on a typical day when you are drinking? (choose one)
1 1 or 2	2 3 or 4		3 5 or 6		4 7 to 9		5 10 or more		6 I never drink

Using the following scale, indicate which best describes how often you felt or behaved this way – DURING THE PAST WEEK.

1 Rarely or none of the time (Less than 1 Day)

2 Some or a Little of the time (1 – 2 Days)

3 Occasionally or a Moderate Amount of Time (3 –4 Days)

4 Most or all of the time (5 – 7 Days)

DURING THE PAST WEEK….

I was bothered by things that usually don’t bother me	1	2	3	4
I did not feel like eating: my appetite was poor	1	2	3	4
I felt that I could not shake off the blues even with help from my family or friends	1	2	3	4
I felt that I was just as good as other people	1	2	3	4
I had trouble keeping my mind on what I was doing	1	2	3	4
I felt depressed	1	2	3	4
I felt that everything that I did was an effort	1	2	3	4
I felt hopeful about the future	1	2	3	4
I thought my life had been a failure	1	2	3	4
I felt fearful	1	2	3	4
My sleep was restless	1	2	3	4
I was happy	1	2	3	4
I talked less than usual	1	2	3	4
I felt lonely	1	2	3	4
People were unfriendly	1	2	3	4
I enjoyed life	1	2	3	4
I had crying spells	1	2	3	4
I felt sad	1	2	3	4
I felt that people disliked me	1	2	3	4
I could not get “going”	1	2	3	4

What is your current job title?
How long have you worked for your present employer?
Do you have any jobs besides this one or do any other work for pay?
Are you a salaried or hourly wage worker?
How many hours per week do you normally work (not including overtime)?
How many hours per week do you spend commuting to and from work?
How many hours overtime do you work in an average week?
What is your gender?						Male	Female
How old were you on your last birthday (in years)?
Are you:
married	member of an unmarried couple	never married		separated		divorced		widowed
Is your spouse or partner employed?						Y	N
Are you Hispanic or Latino?						Y	N
12. Which one or more of the following would you say is your race?			____ American Indian or Alaska Native
			____ Asian
			____ Black or African American
			____ Native Hawaiian or Other Pacific Islander
			____ White
			____ Other: (Please specify_____________________)
What is the highest grade of school you ever completed?					_____ Less than high school
					_____ HS diploma or equivalent
					_____ Some college or technical training
					_____ Bachelor’s degree
					_____ Graduate degree
What is your combined family income (from all sources)?					_____ < $20,000
					_____ $20,001 - $40,000
					_____ $40,001 - $60,000
					_____ $60,001 - $80,000
					_____ $80,001 - $100,000
					_____ $101,001 - $120,000
					_____ > $120,000

Why did you leave your prior employer?			_____ Company reduction in work force
			_____ Fired / let go
			_____ Better opportunity / higher pay
			_____ Graduated from school
			_____ Changed line of work
			_____ Relocated
			_____ Medical / family / personal reasons
			_____ Other (Please specify:_______________)
If you have children living at home, how many are in each of the following age groups?
____< 3 years old	____3-6 years old	____ 7-12 years old		____13-18 years old	____19 and over