Harambee Employee Health Questionnaire


All information will be kept confidential.


Your participation in this survey is important in one way:

You are helping to give an overall picture of employee health needs which will influence health activities developed by Harambee.

Your participation is voluntary. There are no right or wrong answers. If some questions make you uncomfortable, you do not have to answer them.

Instructions



Please read each question carefully, and answer as accurately as you can. Your answers are confidential.
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1. Sex



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2. Age

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3. What is your present status:






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4. What is your highest level of education?:






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5. Does your work involve the following? ( include all jobs):







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6. Do you have other people (for example, elderly parents, someone with a disability) for whom you are completely or partly responsible?:



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7. How tall are you (without shoes)? (Feet, Inches):

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8. How much do you weigh? (If you are pregnant, please record your average weight in the year before you were pregnant.):

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9. Do you consider yourself?:





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10. In general would you say your health is:






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11. Are you happy with your health insurance plan?



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12. Do you have a good relationship with your Doctor?:



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13. If you could change one thing about you..what would it be?:

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Males: Move on to question #19

14. Female: How long has it been since you had a Pap test?:








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15. Female: How often do you examine your breasts?:






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16. Female: Have you ever had a mammogram? (breast x-ray?):







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17. Female: Are you going to the Doctor’s for an annual visit?




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18. Male: Do you go to the Doctor’s office if you are having issues with your health?:





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19. Are you going to the Doctor’s for a Cholesterol check?:




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20. Do you take other steps to insure you are healthy?:



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21. What would you do if you were told that you are placing your health at risk? Please check all that apply.











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22. In the last year, how many days in total were you away from work because of the following?

Sick





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Injured and disabled





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Stress Days





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Family Issues





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23. In a typical week, how often do you spend at least 60 minutes at a time in light physical activity? (Light physical activity refers to such things as: taking a stroll, light gardening, housecleaning, bowling, stretch exercises, etc.):






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24. In a typical week, how often do you spend at least 30 minutes at home in moderate physical activity? (Moderate physical activity involves breathing much harder than normally and the body feeling warm from doing such things as: brisk walking, bicycling, recreational swimming, golfing, heavy gardening, etc.)






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25. In a typical week, how often do you spend at least 20 minutes at a time in vigorous physical activity? (Vigorous physical activity involves breathing much harder than normally and feeling so warm that you are sweating from doing such things as: aerobics, using exercise machines, fast bicycling, fast walking, running, racquet sports, moving heavy objects, competitive swimming, etc.)






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26. How many hours of leisure time do you spend per day at:

Computer

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Television

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Video Games

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27. Here are a number of statements describing various levels of physical activity. Please select the one which most closely describes your own level: (Please choose one)






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28. Would you say your eating habits are:





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29. What would you like to do in the next year to improve how, when, what or how much you eat? Please check all that apply.













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30. Of all the things you checked above, what is the single most important thing you would like to do to improve how, when, what or how much you eat in the next year? Write the number from the list above here:

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31. What is stopping you from improving how, when, what or how much you eat? Please check all that apply.











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32. At the present time do you smoke cigarettes or use other tobacco products (e.g., cigars, pipes, chewing tobacco)?




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33. Which of the following statements best describes you?







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34. In the last month, how often did you use medication or prescription drugs to help you in:

Sleep







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Relieve Stress







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Relieve Pain







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Relieve Depression







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35. Do you use herbal remedies of any kind?



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If yes, which ones and how often?

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36. How many hours do you usually sleep every night (or day, if on shiftwork)?





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37. Do you have trouble sleeping?




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Stress




38. Please indicate the appropriate response for each of the following statements:

Overall, what level of stress do you experience at work?






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Overall, what level of stress do you experience outside of work?






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Overall, how well do you feel you are coping with stress at work?






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Overall, how well do you feel you are coping with stress outside of work?






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39. What would you like to do to cope better with stress? Please check all that apply.





















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40. When you are worried, upset or under stress, how many people can you really count on to understand how you are feeling?




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41. During the last year, did you seek help or counselling for a non-medical, personal or emotional problem of any kind?




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Job Stress and Job Satisfaction




42. For each of the following statements, please check the box that applies to you:

“I am satisfied with the amount of involvement I have in decisions that affect my work”








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“I feel I am well rewarded for the level of effort I put into my job.”








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“In the last six months, too much time pressure at work has caused me excess worry or stress” (e.g., unrealistic workload expectations.)








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43. Your feelings about your work can contribute to the stress and wellness you experience in the workplace. For the following statements, please check the appropriate box.

I have an influence over the things that happen to me at work.






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My employer knows that stress at work can have bad effects on employee’s health.






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My employer makes every effort to keep unnecessary stress at work to a minimum.






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My employer has a sincere interest in the well being of it’s employees






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On the whole, I like my job.






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I look outside of my job for my main satisfaction in life.






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I have one or 2 good friends at work.






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I feel comfortable around my co-workers






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44. What would you do if your supervisor told you to do something that you thought was dangerous for your health and safety?





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45. What methods of delivery program/policy would you prefer? Please check all those you would like.










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46. What time of day would best suit you?






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47. Will you participate in workplace health programs on your own time?



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48. Partly on your time & partly on work time?



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49. Only on work time?



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50. If there was an opportunity to do so, would you be interested in having members of your family participate in a health program at your workplace?




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Thank you for taking the time to complete this questionnaire!