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* 1. Today's date:

Date

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* 2. Check correct department:

Please circle the appropriate response. You may skip ANY question that you feel uncomfortable answering. 
Using the following rating scale, circle the number after each statement that best describes you experience:

1 Strongly Disagree   2 Disagree   3 Not Sure   4 Agree   5 Strongly Agree   0 Does Not Apply To Me


Because we want this survey to remain anonymous, there is no identifying information asked for on it. However, because we have found that men and women often have different responses to these questions.

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* 3. Please indicate your gender here if you wish:

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* 4. Staff input pertaining to program decision making is given appropriate weight.

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* 5. The way this building is decorated-flooring,furniture,wall paint, and artwork- has a calming, inviting effect.

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* 6. Employees are respectful of each other's moods and feelings.

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* 7. I have no concerns for my safety while at work. 

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* 8. Staff here feel supported when they try to find new and better ways to do things.

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* 9. I am comfortable with my colleagues at work.

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* 10. Personal information about me or my family is kept confidential by my supervisor or Human Resources. 

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* 11. The program has a consistent method of reviewing staff for evaluations and promotions.

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* 12. A great deal of importance is placed on personal and professional development.

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* 13. Staff here have a lot of freedom of choice.

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* 14. Staff members from different levels participate in committees. 

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* 15. My job description is very clear and the expectations are fair. 

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* 16. Every day at work, I have the chance to make a real difference. 

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* 17. I can trust my supervisor to be fair in dealing with all staff.

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* 18. There is a lot of flexibility in how I do my job. 

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* 19. I have many choices when it comes to doing my job.

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* 20. Materials and equipment that I use often for my work are up to date.

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* 21. For the most Part, I can decide when to take time off.

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* 22. I feel like I have a great deal of control over my job satisfaction. 

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* 23. When program policies are revised, staff input is taken seriously.

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* 24. Staff at this facility work well together as a team.

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* 25. There are opportunities for me to gain additional skills through workshops and training seminars.

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* 26. Leadership here listen fairly to everyone involved before making important decisions.

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* 27. There are locations within the building where I can relax and de-stress.

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