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* 1. Did any specific person and/or organization refer you to us? If so, who?

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* 2. How significant are the following challenges?

	Not significant	Slightly significant	Significant	Very significant	Extremely significant
Engagement/Getting more done with fewer people/Controlling labor costs	Engagement/Getting more done with fewer people/Controlling labor costs Not significant	Engagement/Getting more done with fewer people/Controlling labor costs Slightly significant	Engagement/Getting more done with fewer people/Controlling labor costs Significant	Engagement/Getting more done with fewer people/Controlling labor costs Very significant	Engagement/Getting more done with fewer people/Controlling labor costs Extremely significant
Increasing revenue/Sales	Increasing revenue/Sales Not significant	Increasing revenue/Sales Slightly significant	Increasing revenue/Sales Significant	Increasing revenue/Sales Very significant	Increasing revenue/Sales Extremely significant
Drama and conflict between employees and supervisors	Drama and conflict between employees and supervisors Not significant	Drama and conflict between employees and supervisors Slightly significant	Drama and conflict between employees and supervisors Significant	Drama and conflict between employees and supervisors Very significant	Drama and conflict between employees and supervisors Extremely significant
Work quality	Work quality Not significant	Work quality Slightly significant	Work quality Significant	Work quality Very significant	Work quality Extremely significant
Hiring/Firing mistakes (frequency, severity and costs)	Hiring/Firing mistakes (frequency, severity and costs) Not significant	Hiring/Firing mistakes (frequency, severity and costs) Slightly significant	Hiring/Firing mistakes (frequency, severity and costs) Significant	Hiring/Firing mistakes (frequency, severity and costs) Very significant	Hiring/Firing mistakes (frequency, severity and costs) Extremely significant
Speed and cost of recruiting	Speed and cost of recruiting Not significant	Speed and cost of recruiting Slightly significant	Speed and cost of recruiting Significant	Speed and cost of recruiting Very significant	Speed and cost of recruiting Extremely significant
Unwanted employee turnover	Unwanted employee turnover Not significant	Unwanted employee turnover Slightly significant	Unwanted employee turnover Significant	Unwanted employee turnover Very significant	Unwanted employee turnover Extremely significant
Theft (fake injuries, time, expense accounts, products, etc)	Theft (fake injuries, time, expense accounts, products, etc) Not significant	Theft (fake injuries, time, expense accounts, products, etc) Slightly significant	Theft (fake injuries, time, expense accounts, products, etc) Significant	Theft (fake injuries, time, expense accounts, products, etc) Very significant	Theft (fake injuries, time, expense accounts, products, etc) Extremely significant
Training time and expenses	Training time and expenses Not significant	Training time and expenses Slightly significant	Training time and expenses Significant	Training time and expenses Very significant	Training time and expenses Extremely significant
Career path/Succession planning to prepare people in advance	Career path/Succession planning to prepare people in advance Not significant	Career path/Succession planning to prepare people in advance Slightly significant	Career path/Succession planning to prepare people in advance Significant	Career path/Succession planning to prepare people in advance Very significant	Career path/Succession planning to prepare people in advance Extremely significant

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* 3. What best describes the scope of your responsibility?

National

Regional

Local

Other (please specify)

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* 4. What is your industry/business purpose?

(beverage distribution, retail furniture, banking, commercial printing, etc.)

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* 5. How many employees do you have?

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* 6. How many locations does your company have?

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* 7. Approximately how many of your employees are in salaried, non-sales positions?

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* 8. Approximately how many salespeople does your company have?

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* 9. Please estimate the projected number of "new hires" likely to fill the following positions in the next 12 months.

Salaried postitions

Sales positions

Hourly positions

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* 10. Contact Information:

Name:

Company:

Address:

Address 2:

City/Town:

State:

ZIP/Postal Code:

Email Address:

Phone Number: