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Work Life Balance Feedback Questionnaire

This questionnaire is designed to help you give your perceptions on the work life balance of the person who requested feedback from you.

There are 16 questions.

When you have completed the questionnaire you will be able to decide if you would like to send your feedback attributed, by putting your name with your feedback, or if you would prefer to remain anonymous.

To minimise the number of clicks you have to use, you will automatically be taken to the next question when you select your response.

If you want to go back and change your response click on Back, and you will be taken back to your previous response.

The person you are giving feedback to is referred to as 'X'.

Continue

Question 1/16

Does X work and/or do chores for long periods without a break?

Often
Sometimes
Never/Rarely

Question 2/16

Does X take work home/work in the evenings or weekends?

Often
Sometimes
Never/Rarely

Question 3/16

Do other people tell X to relax?

Often
Sometimes
Never/Rarely

Question 4/16

Does X use expressions such as 'I must', 'I should' 'I need' 'I have to'?

Often
Sometimes
Never/Rarely

Question 5/16

Does X react with a sudden burst of emotion when one more thing goes wrong? Is X on a short fuse? Often
Sometimes
Never/Rarely

Question 6/16

Does X agree to do things when they would benefit more from saying no? Often
Sometimes
Never/Rarely

Question 7/16

Does X appear to take things on because they are afraid of annoying or disappointing someone else? Often
Sometimes
Never/Rarely

Question 8/16

Are X's shoulders hunched? Do they walk with their head down? Often
Sometimes
Never/Rarely

Question 9/16

Do you see signs that X tends to be ahead of him/herself, with their mind on the next task as they tackle their current task? Often
Sometimes
Never/Rarely

Question 10/16

Does X take everything very seriously failing to see the funny or lighter side of life? Often
Sometimes
Never/Rarely

Question 11/16

Is X always on the go? Do you see signs they feel guilty or uncomfortable if they are not doing something? Often
Sometimes
Never/Rarely

Question 12/16

Does X appear to operate on 'automatic pilot', wrapped up in their thoughts not noticing what they're actually doing? Often
Sometimes
Never/Rarely

Question 13/16

When X is not working does work or his/her list of undone chores seem to be worrying them? Often
Sometimes
Never/Rarely

Question 14/16

Does X appear to dread the prospect of Monday morning? Often
Sometimes
Never/Rarely

Question 15/16

Do you see signs that X feels frustrated or impatient? Often
Sometimes
Never/Rarely

Question 16/16

Do you see any signs that X dreams of escaping to a different type of life? Often
Sometimes
Never/Rarely

Thank You

Thank you for completing the questionnaire. For the person to whom you are sending your feedback please enter ...

His/her First Name:

His/her Email Address:

If you would like the person to know that your feedback came from you please enter your name in the box below. Leave the box blank if you would like to remain anonymous.
Your Name:

When you click on the Send Feedback button below your responses will be emailed to the person to whom you are giving feedback. You will be redirected to a page with all your responses so you can print them out for your own records.

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