Form 0920 Medical History

Attachment D3

Spielberger Stress Survey

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/20xx

Spielberger Stress Survey

ID Number __________

I. This section contains a list of job-related items that have been identified by police officers as stressful. Please rate each item as follows:

1. In the stress rating column below, please mark from 0-100 how stressful you think this event might be for a police officer. The higher the score, the more stressful the item. Please assign a stress rating, even if you have not experienced this event.

2. Mark an “X” for the number of times that you have personally experienced the item within the past month and during the past year.

		Stress Rating (0-100)	Mark an “X” for the Number of Times this Event Occurred
			In the Past Month							In the Past Year
			0	1		2	3-5	6-9	10+	0	1	2-5	6-10	11-24	25+
1	Assignment of disagreeable duties
2	Changing from day to night shift
3	Assignment to new or unfamiliar duties
4	Fellow officers not doing their job
5	Court leniency with criminals
6	Political pressure from within the department
7	Political pressure from outside the department
			In the Past Month							In the Past Year
			0	1	2		3-5	6-9	10+	0	1	2-5	6-10	11-24	25+
8	Incapacitating physical injury on the job
9	Working a second job
10	Strained relations with non-police friends
11	Exposure to death of civilians
12	Inadequate support by supervisor
13	Inadequate support by department
14	Court appearances on day off or day following night shift

Public reporting burden of this collection of information is estimated to average 7 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (XXXX).

		Stress Rating (0-100)	Mark an “X” for the Number of Times this Event Occurred
			In the Past Month											In the Past Year
			0		1		2		3-5		6-9		10+	0	1	2-5	6-10	11-24	25+
15	Assignment of incompatible partner
16	Delivering a death notification
17	Periods of inactivity and boredom
18	Dealing with family disputes and crisis situations
19	High-speed chases
20	Difficulty getting along with supervisors
21	Responding to a felony in progress
22	Experiencing negative attitudes toward police officers
		Stress Rating (0-100)	In the Past Month											In the Past Year
			0	1		2		3-5		6-9		10+		0	1	2-5	6-10	11-24	25+
23	Public criticism of police
24	Disagreeable departmental regulations
25	Confrontations with aggressive crowds
26	Fellow officer killed in the line of duty
27	Distorted or negative press accounts of police
28	Making critical on-the-spot decisions
29	Ineffectiveness of the judicial system
30	Ineffectiveness of the correctional system

		Stress Rating (0-100)	In the Past Month									In the Past Year
			0	1		2	3-5		6-9		10+	0	1	2-5	6-10	11-24	25+
31	Personal insult from citizen
32	Insufficient manpower to adequately handle a job
33	Lack of recognition for good work
34	Excessive or inappropriate discipline
35	Performing non-police tasks
36	Demands made by family for more time
37	Promotion or commendation
38	Inadequate or poor quality equipment
		Stress Rating (0-100)	In the Past Month									In the Past Year
			0		1	2		3-5		6-9	10+	0	1	2-5	6-10	11-24	25+
39	Assignment of increased responsibility
40	Racial pressures or conflicts
41	Lack of participation on policy-making decisions
42	Inadequate salary
43	Accident in a patrol car
44	Physical attack on one’s person
45	Demands for high moral standards
46	Situations requiring use of force

		Stress Rating (0-100)	In the Past Month											In the Past Year
			0	1		2		3-5		6-9		10+		0	1	2-5	6-10	11-24	25+
47	Job conflict (by-the-book vs. by-the-situation)
48	Court decisions unduly restricting police
49	Killing someone in the line of duty
50	Making arrests while alone
51	Public apathy toward police
52	Competition for advancement
53	Poor or inadequate supervision
		Stress Rating (0-100)	In the Past Month											In the Past Year
			0		1		2		3-5		6-9		10+	0	1	2-5	6-10	11-24	25+
54	Exposure to battered or dead children
55	Plea bargaining and technical rulings leading to case dismissal
56	Frequent changes from boring to demanding activities
57	Exposure to adults in pain
58	Possibility of minor physical injury on the job
59	Put-downs and mistreatment of police officers in court
60	Excessive paperwork