Copyright © Health Sponsorship Council. This sheet can be photocopied and adapted for school use only.

This appendix provides examples of the types of questions you could ask in your surveys – depending on your research objectives. These questions come from the National ASH Year 10 Snapshot Survey, the Year 10 In-depth Survey, and the Health and Lifestyles Survey. It is a good idea to use questions that have been used in national surveys because they have been developed by researchers and are valid measures. It also means you can compare your fi ndings against a benchmark.The appendix isn’t an exhaustive list of questions, but it does provide a starting point for creating your own questionnaires. You may also fi nd it useful to look at examples of other questions. Links to useful surveys are given at the end of this appendix.

EthnicityWhich ethnic groups do you belong to?Please tick allboxes that apply.New Zealand European Other Pacifi c Islands nationMāori ChineseSamoan IndianCook Islands Māori Other AsianTongan Other (Please write in.)Niue

Smoking status and smoking susceptibilityThe standard way to defi ne a survey respondent’s smoking status is to ask questions aand bon the next page.

•Never smokers: Those who answer “no” to a

•Experimenter: Those who answer “yes” to aand “I have never smoked/I am not a smoker now” to b

•Current or regular smokers: Those who answer “at least once a day”, “at least once a week”, or “at least once a month” to b

•Daily smokers: Those who answer “at least once a day” to b.Researchers have also developed two questions that tell us how susceptible young people who don’t smoke are to taking up smoking in the future.

•Non-susceptible never smokers: Those who had never smoked and who answered “defi nitely not” to c, d, and e

•Susceptible never smokers: Those who had never smoked but who answered anything except “defi nitely not” to c, d, or e.Our Smokefree School He Kura Auahi KoreA Practical Guide to Being a Smokefree CommunityAppendix V:Sheet 1 of 8

Some possible survey questions Copyright © Health Sponsorship Council. This sheet can be photocopied and adapted for school use only.

Our Smokefree School He Kura Auahi KoreA Practical Guide to Being a Smokefree CommunityAppendix V:Sheet 2 of 8a.Have you ever smoked a cigarette, even just a few puffs?Ye s Nob.How often do you smoke now? Please tick onebox only.I have never smoked/I am not a smoker now At least once a dayAt least once a week At least once a month Less often than once a monthc.If one of your best friends offered you a cigarette, would you smoke it? Please tick onebox only.Defi nitely not Probably not Probably yes Defi nitely yes d.At any time during the next year (12 months) do you think you will smoke a cigarette? Please tick onebox only.Defi nitely not Probably not Probably yes Defi nitely yes e.Do you think you will try a cigarette soon? Please tick onebox only.Defi nitely not Probably not Probably yes Defi nitely yes

Quitting attemptsDuring the past year (12 months), have you ever tried to stop smoking cigarettes? Please tick onebox only.I have never smoked cigarettes. I did not smoke during the past year.Yes, I have tried to stop smoking cigarettes. No, I have not tried to stop smoking.

Access to tobacco During the past 30 days (one month), how did you usually get your own cigarettes? Please tick onebox only.I have never smoked/I am not a smoker now. I bought them from a shop. I bought them from a vending machine.A friend/friends or person my age gave them to me. A parent or caregiver gave them to me. I took them from a parent or caregiver without asking. I got them from an older brother or sister. I got them some other way.Copyright © Health Sponsorship Council. This sheet can be photocopied and adapted for school use only.

Attitudes towards tobacco useYou could use a selection of the following questions to fi nd out what your students think about smoking and smokers. For each statement listed below, please indicate whether you agree or disagree with it. Please tick onebox for each statement.1. Smokers are more popular. Agree Disagree Don’t know 2. Smoking helps people forget their worries.Agree Disagree Don’t know 3. Non-smokers dislike being around people who are smoking.Agree Disagree Don’t know4. Smokers find it hard to get dates.

Agree Disagree Don’t know5. Smokers are tough.Agree Disagree Don’t know 6. Smoking is something you need to try before deciding to do it or not.Agree Disagree Don’t know 7. Smoking makes people look more grown-up.Agree Disagree Don’t know 8. There is no harm in having a cigarette once in a while.Agree Disagree Don’t know 9. Smoking helps people relax.Agree Disagree Don’t know 10. Seeing someone smoking turns me off.Agree Disagree Don’t know 11. Smokers are often stressed.Agree Disagree Don’t know12. Smoking is enjoyable.Agree Disagree Don’t know 13. Smoking makes people look sexy.Agree Disagree Don’t know14. Non-smokers should be proud to be smokefree/auahi kore.Agree Disagree Don’t knowOur Smokefree School He Kura Auahi KoreA Practical Guide to Being a Smokefree CommunityAppendix V:Sheet 3 of 8Copyright © Health Sponsorship Council. This sheet can be photocopied and adapted for school use only.Our Smokefree School He Kura Auahi KoreA Practical Guide to Being a Smokefree Community

Appendix V:Sheet 4 of 8

Attitudes towards tobacco regulation, the tobacco industry, and the idea of a smokefree/auahi kore New ZealandFor each statement listed below, please indicate whether you agree or disagree with it. Please answer every question.Tick onebox on each line.1. Smoking should be banned in all outdoor places where young people go. Agree Disagree Don’t know 2. There should be fewer places where cigarettes and tobacco can be sold.Agree Disagree Don’t know 3. Tobacco companies should not be allowed to promote cigarettes and tobacco with cool-looking packs.Agree Disagree Don’t know4. Cigarettes and tobacco should be made more expensive so that children and young people can’t afford to buy them.Agree Disagree Don’t know 5. Cigarettes and tobacco should not be sold in New Zealand in 10 years’ time.Agree Disagree Don’t know 6. It’s not OK for people to smoke around me where I can breathe their smoke.Agree Disagree Don’t know7. I want to live in a country where no one smokes.Agree Disagree Don’t know

Knowledge of harm1. Do you think cigarette smoking is harmful to your health? Please tick onebox only.

Defi nitely not Probably not Probably yes Defi nitely yes2. Do you think the smoke from other people’s cigarettes is harmful to you? Please tick onebox only.Defi nitely not Probably not Probably yes Defi nitely yes

Smoking by family, friends, and teachersWhich of the following people smoke? Please tick allthat apply.Best friend Other close friends Father Mother Grandparents A teacher at school Other caregiver (e.g., stepfather or stepmother, foster parents) Olderbrother(s) Oldersister(s) None of the aboveCopyright © Health Sponsorship Council. This sheet can be photocopied and adapted for school use only.Our Smokefree School He Kura Auahi KoreA Practical Guide to Being a Smokefree CommunityAppendix V:Sheet 5 of 8

Second-hand smoke exposure During the past 7 days, on how many days have people smoked around you in your home? Please tick onebox only.0 1 to 2 3 to 4 5 to 6 7During the past 7 days, on how many days have people smoked in your presence in places other than in your home? Please tick

onebox only.0 1 to 2 3 to 4 5 to 6 7During the past 7 days, on how many days have people smoked around you in your home? Please tick onebox only.0 1 to 2 3 to 4 5 to 6 7

Exposure to the role-modelling of smokingDuring the past month (30 days), how often have you noticed people smoking in the following places? Please tick onebox for eachplace.1. Local parks or reserves A lot Sometimes Never Didn’t go there2. Outdoor children’s playgrounds A lot Sometimes Never Didn’t go there3. At school A lot Sometimes Never Didn’t go there4. Outdoor sports fi elds or courtsA lot Sometimes Never Didn’t go there

5. Outdoors at a marae A lot Sometimes Never Didn’t go there6. Outside doorways to public buildings A lot Sometimes Never Didn’t go there7. Beaches A lot Sometimes Never Didn’t go there8. Outdoor seating areas of bars/restaurants/cafesA lot Sometimes Never Didn’t go thereCopyright © Health Sponsorship Council. This sheet can be photocopied and adapted for school use only.Our Smokefree School He Kura Auahi KoreA Practical Guide to Being a Smokefree CommunityAppendix V:Sheet 6 of 8

Young people’s reporting of parental rules and monitoring around smokingFor each statement listed below, please indicate whether you agree or disagree with it. Please tick onebox for eachstatement.1. My parents or caregivers have set rules with me about not smoking cigarettes or tobacco. Agree Disagree Don’t know 2. My parents or caregivers generally know what I spend my pocket money on. Agree Disagree Don’t know 3. My parents or caregivers have rules about when I can go out with my friends. Agree Disagree Don’t know 4. My parents or caregivers often have no idea where I am when I am away from my home.

Agree Disagree Don’t know 5. My parents or caregivers know about my school life (e.g., my teachers, my grades). Agree Disagree Don’t know 6. My parents or caregivers would be upset if I was caught smoking cigarettes or tobacco. Agree Disagree Don’t know 7. If I break any important rules that my parents or caregivers have set, I always get into trouble. Agree Disagree Don’t know Copyright © Health Sponsorship Council. This sheet can be photocopied and adapted for school use only.Our Smokefree School He Kura Auahi KoreA Practical Guide to Being a Smokefree CommunityAppendix V:Sheet 7 of 8

Parenting and tobacco This includes the extent to which parents believe they can infl uence whether their children smoke and the extent to which they tell their children not to smoke. Your choice of questions will depend on the age of the children.As a parent or caregiver, do you have any infl uence over whether Xxx starts to smoke cigarettes or tobacco?Ye s No Not applicable – child too young Other Don’t know RefusedDo you think you will have any infl uence over whether Xxx starts to smoke cigarettes or tobacco when he or she is older?Ye s No Don’t know RefusedDo you think you are able to prevent Xxx from starting to smoke cigarettes or tobacco?Ye s No Not applicable – child too young Other Don’t know Refused

Do you think you will be able to prevent Xxx from starting to smoke cigarettes or tobacco when he or she is older?Ye s No Don’t know RefusedHow often do you tell Xxx that you don’t want him or her to smoke cigarettes or tobacco?Never Rarely Sometimes Often Very often Not applicable/Other Don’t know RefusedDo you have set rules with Xxx about not smoking cigarettes or tobacco?Ye s No Not applicable/Other Don’t know Refused

More questionsASH Year 10 Snapshot Survey This survey is conducted yearly and is used to work out smoking rates among 14-15-year-old students. If your school has year 10 students, you would have received an invitation to participate. Action on Smoking and Health (ASH) provides schools with their own school-level smoking rates for year 10 students. You may fi nd this information useful for informing or evaluating your smokefree activities. The questionnaires from these surveys are available on the Internet at www.ash.org.nz/?t=182

Year 10 In-depth SurveyThe Health Sponsorship Council (HSC) has conducted this survey biennially, in 2006, 2008, and 2010. It includes questions on:

•attitudes and behaviours around smoking (for example, attitudes towards tobacco companies, on whether smoking should be allowed in cars, in movies, or in magazines, on effectiveness in quitting, on the extent to which respondents got help to quit)

•other known protective or risk factors for smoking uptake, for example, connectedness to schools, peers, and family

•access to tobacco (for example, experiences of trying to buy tobacco)

•where people smoke. The questionnaire is available on the Internet at http://www.hsc.org.nz/researchpublications.htmlCopyright © Health Sponsorship Council. This sheet can be photocopied and adapted for school use only.Our Smokefree School He Kura Auahi KoreA Practical Guide to Being a Smokefree CommunityAppendix V:Sheet 8 of 8

The Health and Lifestyles Survey (HLS)The Health Sponsorship Council started the Health and Lifestyles Survey (HLS) in 2008, and it was conducted again in 2010. It includes questions on topics such as smoking, quitting, what prompted quitting, attitudes towards smoking in outdoor areas, the extent to which smoking or tobacco is seen as a problem, attitudes to tobacco regulation, and parental infl uence on smoking.This survey is available on the Internet at http://www.hsc.org.nz/researchpublications.html

Centers for Disease Control Question Inventory on TobaccoCenters for Disease Control Question Inventory on Tobacco is a searchable database of tobacco survey questions.The database is available on the Internet at http://apps.nccd.cdc.gov/qit/QuickSearch.aspx

The New Zealand Tobacco Use SurveyThe Ministry of Health’s New Zealand Tobacco Use Survey (NZTUS) also has standardised questions. This questionnaire is available on the Internet at http://www.moh.govt.nz/moh.nsf/indexmh/dataandstatistics-survey-tobaccouseSince April 2011, the NZTUS has been integrated into the New Zealand Health Survey. See http://www.moh.govt.nz/moh.nsf/indexmh/dataandstatistics-survey-nzhealth

International Tobacco Control Policy Evaluation ProjectThe New Zealand arm of this project is run by the University of Otago Wellington School of Medicine. The questionnaire is available on the Internet at http://www.wnmeds.ac.nz/academic/dph/research/HIRP/Tobacco/itcproject.html

Global Schools Personnel SurveyIf you are wanting to survey school staff, some of the questions from this survey might be useful. Topics covered are tobacco use, attitudes and knowledge, school procedures, and school curriculum. Note that some of the questions won’t be relevant in the New Zealand context.

This questionnaire is available on the Internet at http://www.cdc.gov/tobacco/global/gsps/questionnaire/index.htm

http://www.stress.org/wp-content/uploads/2011/08/Workplace-Stress-Survey.pdf

Workplace Stress Survey http://www.stress.org/wp-content/uploads/2011/08/Workplace-Stress-Survey.pdfEnter a number from the sliding scale below, which best describes you.STRONGLY DISAGREEAGREE SOMEWHATSTRONGLY AGREE

1 2 3 4 5 6 7 8 9 10I can’t honestly say what I really think or get things off my chest at work.______My job has a lot of responsibility, but I don’t have very much authority.______I could usually do a much better job if I were given more time.______I seldom receive adequate acknowledgement or appreciation when my work is really good.______In general, I am not particularly proud or satisfied with my job.______I have the impression that I am repeatedly picked on or discriminated against at work. ______My workplace environment is not very pleasant or safe.______My job often interferes with my family and social obligations, or personal needs. ______I tend to have frequent arguments with superiors, coworkers or customers. ______Most of the time I feel I have very little control over my life at work. ______Add up the replies to each question for your TOTAL JOB STRESS SCORE______If you score between 10-30, you handle stress on your job well; between 40-

60, moderately well; 70-100 you are encountering problems that need to be resolved.

WORK-RELATED STRESSQUESTIONNAIREThis questionnaire is closely based on the Management Standards Indicator Tool produced by the HSE (Health and Safety Executive).The Management Standards define the characteristics, or culture, of an organisation where the risks from work-related stress are being effectively managed and controlled.The questionnaire is being issued by UNITE Health and Safety Representatives within Fujitsu following reports

of work-related stress in some parts of ITG.The enclosed covering letter provides more information.Instructions: It is recognised that working conditions affect worker well-being. Your responses to the questions below will help us determine our working conditions now, and enable us to monitor future improvements. In order for us to compare the current situation with past or future situations, it is important that your responses reflect your work in the last six months.1.I am clear what is expected of me at workNever1Seldom2Sometimes3Often4Always5

2.I can decide when to take a break Never1Seldom2Sometimes3Often4Always5

3.Different groups at work demand things from me that

are hard to combineNever5Seldom4Sometimes3Often2Always1

4.I know how to go about getting my job done Never1Seldom2Sometimes3Often4Always5

5.I am subject to personal harassment in the form of unkind words or behaviour Never5Seldom4Sometimes3Often2Always1

6.I have unachievable deadlinesNever5Seldom4Sometimes3Often2Always1

7.If work gets difficult, my colleagues will help meNever1Seldom2Sometimes3Often4Always5

8.

I am given supportive feedback on the work I doNever1Seldom2Sometimes3Often4Always5

9.I have to work very intensivelyNever5Seldom4Sometimes3Often2Always1

10.I have a say in my own work speedNever1Seldom2Sometimes3Often4Always5

11.I am clear what my duties and responsibilities areNever1Seldom2Sometimes3Often4Always5

12.I have to neglect some tasks because I have too much to doNever5Seldom4Sometimes3Often2Always1

13.I am clear about the goals and objectives for my departmentNever

1Seldom2Sometimes3Often4Always5

14.There is friction or anger between colleaguesNever5Seldom4Sometimes3Often2Always1

15.I have a choice in deciding how I do my workNever1Seldom2Sometimes3Often4Always5

16.I am unable to take sufficient breaksNever5Seldom4Sometimes3Often2Always1

17.I understand how my work fits into the overall aim of the organisationNever1Seldom2Sometimes3Often4Always5

18.I am pressured to work long hoursNever5

Seldom4Sometimes3Often2Always1

19.I have a choice in deciding what I do at workNever1Seldom2Sometimes3Often4Always5

20.I have to work very fastNever5Seldom4Sometimes3Often2Always1

21.I am subject to bullying at workNever5Seldom4Sometimes3Often2Always1

22.I am aware of others being subject to bullying at workNever5Seldom4Sometimes3Often2Always1

23.If I were aware of bullying I would feel able to challenge itNever1Seldom

2Sometimes3Often4Always5

24.If I reported bullying, I would be confident that it would be stoppedNever1Seldom2Sometimes3Often4Always5

25.I have unrealistic time pressuresNever5Seldom4Sometimes3Often2Always1

26.I can rely on my line manager to help me out with a work problemNever1Seldom2Sometimes3Often4Always5

27.I get help and support I need from colleaguesStrongly disagree1Disagree2Neutral3Agree4Strongly agree5

28.I have some say over the way I workS

trongly disagree1Disagree2Neutral3Agree4Strongly agree5

29.I have sufficient opportunities to question managers about change at workStrongly disagree1Disagree2Neutral3Agree4Strongly agree5

30.I receive the respect at work I deserve from my colleaguesStrongly disagree1Disagree2Neutral3Agree4Strongly agree5

31.Staff are always consulted about change at workStrongly disagree1Disagree2Neutral3Agree4Strongly agree5

32.I can talk to my line manager about something that has upset or annoyed me about workStrongly disagree1Disagree2

Neutral3Agree4Strongly agree5

33.My working time can be flexibleStrongly disagree1Disagree2Neutral3Agree4Strongly agree5

34.My working location can be flexible (subject to business constraints)Strongly disagree1Disagree2Neutral3Agree4Strongly agree5

35.My colleagues are willing to listen to my work-related problemsStrongly disagree1Disagree2Neutral3Agree4Strongly agree5

36.When changes are made at work, I am clear how they will work out in practiceStrongly disagree1Disagree

2Neutral3Agree4Strongly agree5

37.I am supported through emotionally demanding workStrongly disagree1Disagree2Neutral3Agree4Strongly agree5

38.Relationships at work are strainedStrongly disagree5Disagree4Neutral3Agree2Strongly agree1

39.My line manager encourages me at workStrongly disagree1Disagree2Neutral3Agree4Strongly agree5

Thank you for completing the questionnaire.Please return, as hardcopy, to Phil Tepper at MAN34.

http://www.ourunion.org.uk/news/archives/Stress%20Questionnaire.pdf

1

Introduction

Brought to you by: American Institute for Preventive Medicine

2

Stress Management at Work

3

Type A & B Behavior Patterns

4

Biofeedback Training and Relaxation

5

Thinking Differently

6

Time Management

Home

7

Communication and Stress

Stress Management at Work

Work Stressor Questionnaire

Work stressors can be identified in almost all aspects of one’s job. Before taking action to eliminate or reduce these stressors, pinpoint their sources. Isolate these factors so corrective action can begin.

 

Instructions: Think about how often you encounter the following situations. Rate yourself with the following scale in each category.

1 = Never

2 = Rarely

3 = Occasionally

4 = Usually

5 = Constantly

 

A. Disagreement & Indecision

  Unsure of coworkers expectations

  Unfriendly attitude in coworkers

  Job responsibilities go against your better judgment.

  Can’t satisfy conflicting demands from superiors

  Trouble refusing overtime

 

Section subtotal: 5

 

B. Pressure on the Job

  Overloaded at work, unable to complete tasks during an average day

  Too much supervision

  Job requirements are taking their toll on your private life

  Rushed to complete work or short on time

  Too much red tape

 

Section subtotal: 5

 

C. Job Description Conflict

  Uncertainty about your exact job responsibilities

  Too much teamwork

  Poor flow of information to you in order to carry out your job

  Not enough authority for you to  properly do your job

  Discomfort in handling unethical assignments

 

Section subtotal: 5

 

D. Communications & Comfort with Supervisor

  Ideas differ from those of your supervisor

  Trouble talking to boss

  Unable to predict supervisor’s reactions

  Boss gives little feedback about your work

  Boss is overly critical of your work

 

Section subtotal: 5

 

E. Job Related Health Concerns

  Work conditions are unhealthy

  Physical dangers exist at work place

  Heavy physical tasks to complete

  Hostile threats from co-workers

  Sick days are discouraged

 

Section subtotal: 5

 

F. Work Overload Stress

  Can’t consult with others on projects

  Co-workers are inefficient

  Often take work home to complete

  Responsible for too many people/projects

  Shortage of help at work

 

Section subtotal: 5

 

G. Work Underload Stress

  Too little responsibility at work

  Overqualified for your job

  Little chance for growth exists

  Trying to “look” busy on job

  Feeling unstimulated

 

Section subtotal: 5

 

H. Boredom Induced Stress

  Repetitive or highly specialized routine

  Not learning anything new

  Can’t see final outcome of your efforts

  Job is too easy

  Daydreaming frequently

 

Section subtotal: 5

 

I. Problem of Job Security

  Fear of being laid off or fired

  Worry about poor pension

  Concerned about low wages

  Need “pull” to get ahead

  Could be fired without cause

 

Section subtotal: 5

 

J. Time Pressure

  Constant reminders that “time is money”

  Starting and ending times are rigid

  Monotonous pace of work

  Not enough break or meal time

  Work pace is too fast

 

Section subtotal: 5

 

K. Job Barrier Stress

  Hope for advancement or raise is limited

  Sex/age discrimination exists at job

  Not suited to job

  Work has no personal meaning

  Work goes unrecognized

 

Section subtotal: 5

 

How to Score: Add the numbers you circled within each of the areas and record them. Place a star (*) next to the highest scoring category.

 

A. Disagreement & Indecision

B. Pressure on the Job

C. Job Description Conflict

D. Communication & Comfort with Supervisor

E. Job Related Health Concerns

F. Work Overload Stress

G. Work Underload Stress

H. Boredom Induced Stress

I. Problem of Job Security

J. Time Pressure

K. Job Barrier Stress

 

Your Total Score: 55

 

Within each area, scores will range from 5 to 25. Scores of 14 or above suggest problem areas.

 

Overall scores will fall within the 55 to 275 range. Scores of 135 or above would suggest an unusual amount of work related stress. Use the Ten Tips for Preventing Burnout in the next section to combat the effects of work related stress.

Next Topic

Disclaimer

Copyright © 2012, 4th edition. American Institute for Preventive Medicine. All rights reserved.

http://www.healthylife.com/online/stress/stateofmichigan/work-stessor-questionnaire.html

1WORKSAFE VICTORIA/ STRESSWISE – PREVENTING WORK-RELATED STRESS IN THE PUBLIC SECTOR

ATTACHMENT 2 –SAMPLE SURVEY QUESTIONS FOR WORK-RELATED STRESS2. SAMPLE SURVEY QUESTIONS FOR WORK-RELATED STRESSThe following questions cover the areas that have been found to be the main sources of stress for people at work. Please tick the box that most accurately reflects how you feel about your job at the moment. Please only tick ONE box for each question.

1. I have unrealistic time pressuresOften Sometimes Seldom Never/almost never2. Staff are consulted about change at workOften Sometimes Seldom Never/almost never3. I have some say over the way I workOften Sometimes Seldom Never/almost never4. I am clear about what my duties and responsibilities areOften Sometimes Seldom Never/almost never5. I receive the respect I deserve from my colleagues at workOften Sometimes Seldom Never/almost never6. Staff are exposed to interpersonal conflict at workOften Sometimes Seldom Never/almost never7. My line manager encourages me at workOften Sometimes Seldom Never/almost neverSource: Cousins R, Mackay C, Clarke S, Kelly C, Kelly P and McCaig R, ‘Management Standards and work-related stress in the UK: Practical development’, Work and Stress: a journal of work, health and organisation,18(2), 2004, p.130; and www.hse.gov.uk/stressNote: Privacy and confidentiality of personal information must be protected. Personal information is information or opinion, whether true or not about an identifiable individual. It should not be possible to identify an individual from workplace records, survey data or workplace consultation, therefore grouped or aggregate information is recommended to protect the identity of individuals.Only persons authorised to handle personal information should summarise, aggregate or de-identify personal information.

https://www.worksafe.vic.gov.au/__data/assets/pdf_file/0008/12230/stresswise_att_2.pdf