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Brain Heat Map – General
Step
1
of
2
50%
Name
First
Last
Company
*
Employee ID
Work Area/Department
*
Date
*
DD slash MM slash YYYY
Privacy Statement:
Only aggregate data will be shared with your organisation.
Individual responses will be kept confidential.
Should you prefer to not answer any of the following
questions simply select the X option instead of a number.
Rarely
Mostly
1. At work I am expected to do too many different tasks in too little time
*
1
2
3
4
5
X
2. I feel that my career is progressing about as I hoped it would
*
1
2
3
4
5
X
3. My supervisor provides me with useful feedback about my performance
*
1
2
3
4
5
X
4. I feel conflict between what my employer expects me to do and what I think is right or proper
*
1
2
3
4
5
X
5. I feel I deal with more people during the day than I prefer
*
1
2
3
4
5
X
6. On my job I am exposed to high levels of noise
*
1
2
3
4
5
X
7. I don't seem to be able to get much done at work
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1
2
3
4
5
X
Rarely
Mostly
8. Lately, I am easily irritated
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1
2
3
4
5
X
9. I wish I had more time to spend with my close friends
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1
2
3
4
5
X
10. I have unplanned weight
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1
2
3
4
5
X
11. I feel that my job responsibilities are increasing
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1
2
3
4
5
X
12. I feel that my job fits my skills and interests
*
1
2
3
4
5
X
13. It is clear to me what I have to do to get ahead
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1
2
3
4
5
X
14. I feel caught between factions at work
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1
2
3
4
5
X
Rarely
Mostly
15. I spend time concerned with the problems others at work bring to me
*
1
2
3
4
5
X
16. My work area is comfortable
*
1
2
3
4
5
X
17. I dread going to work, lately
*
1
2
3
4
5
X
18. Lately, I have been depressed
*
1
2
3
4
5
X
19. I quarrel with my spouse
*
1
2
3
4
5
X
20. My eating habits are erratic
*
1
2
3
4
5
X
21. I am expected to perform tasks on my job for which I have never been trained
*
1
2
3
4
5
X
Rarely
Mostly
22. I am bored with my job
*
1
2
3
4
5
X
23. I am uncertain about what I am supposed to accomplish in my work
*
1
2
3
4
5
X
24. I have more than one person telling me what to do
*
1
2
3
4
5
X
25. I am responsible for the welfare of subordinates
*
1
2
3
4
5
X
26. On my job I am exposed to high levels of dust
*
1
2
3
4
5
X
27. I am bored with my work
*
1
2
3
4
5
X
28. Lately, I have been feeling anxious
*
1
2
3
4
5
X
Rarely
Mostly
29. I quarrel with my friends
*
1
2
3
4
5
X
30. I find myself drinking a lot lately
*
1
2
3
4
5
X
31. I have to take work home with me
*
1
2
3
4
5
X
32. I feel I have enough responsibility on my job
*
1
2
3
4
5
X
33. When faced with several tasks I know which should be done first
*
1
2
3
4
5
X
34. I feel I have a stake in the success of my employer (or enterprise)
*
1
2
3
4
5
X
35. People on the job look to me for leadership
*
1
2
3
4
5
X
Rarely
Mostly
36. On my job I am exposed to high temperatures
*
1
2
3
4
5
X
37. I find myself getting behind in my work lately
*
1
2
3
4
5
X
38. I have been happy, lately
*
1
2
3
4
5
X
39. My spouse and I are happy together
*
1
2
3
4
5
X
40. Lately, I have been tired
*
1
2
3
4
5
X
41. I have the resources I need to get my job done
*
1
2
3
4
5
X
42. I feel my talents are being used on my job
*
1
2
3
4
5
X
Rarely
Mostly
43. I know where to begin a new project when it is assigned to me
*
1
2
3
4
5
X
44. I feel good about the work I do
*
1
2
3
4
5
X
45. I have on the job responsibility for the activities of others
*
1
2
3
4
5
X
46. On my job I am exposed to bright light
*
1
2
3
4
5
X
47. I have had accidents on the job of late
*
1
2
3
4
5
X
48. So many thoughts run through my head at night that I have trouble falling asleep
*
1
2
3
4
5
X
49. Lately, I do things by myself instead of with other people
*
1
2
3
4
5
X
50. I have been feeling tense
*
1
2
3
4
5
X
For each of the questions below, click the number from 1 to 5 that best reflects your feelings.
Should you prefer to not answer any of the following
questions simply select the X option instead of a number.
Rarely
Mostly
51. I feel competent in what I do
*
1
2
3
4
5
X
52. I feel my job has a good future
*
1
2
3
4
5
X
53. My supervisor asks for one thing, but really wants another
*
1
2
3
4
5
X
54. My supervisors have conflicting ideas about what I should be doing
*
1
2
3
4
5
X
55. I worry about whether the people who work for/with me will get things done properly
*
1
2
3
4
5
X
56. On my job I am exposed to low temperatures
*
1
2
3
4
5
X
57. The quality of my work is good
*
1
2
3
4
5
X
Rarely
Mostly
58. Lately, I have responded badly in situations that normally wouldn't bother me
*
1
2
3
4
5
X
59. I quarrel with members of the family
*
1
2
3
4
5
X
60. I have trouble falling and staying asleep
*
1
2
3
4
5
X
61. I work under tight deadlines
*
1
2
3
4
5
X
62. I am able to satisfy my needs for success and recognition in my job
*
1
2
3
4
5
X
63. I understand what is acceptable personal behaviour on my job (e.g., dress, personal relations)
*
1
2
3
4
5
X
64. I am proud of what I do for a living
*
1
2
3
4
5
X
Rarely
Mostly
65. People who work for/with me are really hard to deal with
*
1
2
3
4
5
X
66. I feel safe in my work environment
*
1
2
3
4
5
X
67. Recently, I have been absent from work
*
1
2
3
4
5
X
68. I find myself complaining about little things
*
1
2
3
4
5
X
69. Lately, my relationships with people are great
*
1
2
3
4
5
X
70. I have aches and pains I cannot explain
*
1
2
3
4
5
X
71. I wish that I had more help to deal with the demands placed upon me at work
*
1
2
3
4
5
X
Rarely
Mostly
72. I feel overqualified for my job
*
1
2
3
4
5
X
73. The priorities of my job are clear to me
*
1
2
3
4
5
X
74. It is clear who really runs things where I work
*
1
2
3
4
5
X
75. If I make a mistake in my work, the consequences for others can be pretty bad
*
1
2
3
4
5
X
76. My work environment makes me feel isolated
*
1
2
3
4
5
X
77. I find my work interesting and/or exciting
*
1
2
3
4
5
X
78. Lately, I have been worrying
*
1
2
3
4
5
X
Rarely
Mostly
79. I find that I need time to myself to work out my problems
*
1
2
3
4
5
X
80. I eat the wrong foods
*
1
2
3
4
5
X
81. My job requires me to work in several equally important areas at once
*
1
2
3
4
5
X
82. I learn new skills in my work
*
1
2
3
4
5
X
83. I have a clear understanding of how my boss wants me to spend my time
*
1
2
3
4
5
X
84. I have divided loyalties on my job
*
1
2
3
4
5
X
85. My job demands that I handle an angry public
*
1
2
3
4
5
X
Rarely
Mostly
86. On my job I am exposed to unpleasant odours
*
1
2
3
4
5
X
87. I can concentrate on the things I need to at work
*
1
2
3
4
5
X
88. I have a good sense of humour
*
1
2
3
4
5
X
89. I wish I had more time to spend by myself
*
1
2
3
4
5
X
90. I feel apathetic
*
1
2
3
4
5
X
91. I am expected to do more work than is reasonable
*
1
2
3
4
5
X
92. I have to perform tasks that are beneath my ability
*
1
2
3
4
5
X
Rarely
Mostly
93. I know the basis on which I am evaluated
*
1
2
3
4
5
X
94. The work I do has as much payoff for me as for my employer
*
1
2
3
4
5
X
95. I like the people I work with
*
1
2
3
4
5
X
96. I feel crowded in my work environment
*
1
2
3
4
5
X
97. I make errors or mistakes at work
*
1
2
3
4
5
X
98. Things are going about as they should
*
1
2
3
4
5
X
99. I have been withdrawing from people lately
*
1
2
3
4
5
X
Rarely
Mostly
100. I feel lethargic
*
1
2
3
4
5
X
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