QUESTIONNAIRE FOR BIG TOWN EMPLOYEES
This questionnaire was designed to help the Employee Assistance Program of Big Town to
understand and meet your needs. Your honest opinions are important; please take a few
minutes to answer the following questions carefully. Please return your completed
questionnaire to them in the postage-paid envelope.
Finally, your answers to the following questions are completely confidential.
Thank you for taking the time to complete this questionnaire.
If you have any questions, please contact Herbie Jones at the Employee Assistance
Services in Big Town.
INSTRUCTIONS:
Please circle your answers. Remember, there are no right or
wrong answers to these questions.
(1)
Have you been told about the Employee Assistance
Program for city employees? .................................................Yes ..............No
(2)
Were you told that your whole family can use the
Employee Assistance Program? .............................................Yes ..............No
(3)
In the last year, how many times did you or someone in your family visit with an Employee
Assistance Program counselor?
Never
(4)
1 time
2 times
3 times
More than 3 times
In general, how satisfied are you with the Employee Assistance Program?
Very
Satisfied
Somewhat
Satisfied
Not at All
Satisfied
Don't Know/
Never Used
(5)
How interested are you in having the Employee Assistance Program offer each of the
following programs? Please circle:
'1' if you are very interested,
'2' if you are somewhat interested, and
'3' if you are not at all interested.
Very
Somewhat
Not at All
Interested
Interested
Interested
----------------------------------------------------How to build work teams ...........................................1......................2......................3
How to communicate with co-workers ......................1......................2......................3
How to fix job performance problems .......................1......................2......................3
How to manage employee conflict ............................1......................2......................3
How to become a better parent ..................................1......................2......................3
How to communicate within my family ....................1......................2......................3
How to increase my confidence .................................1......................2......................3
How to handle constant body pains ...........................1......................2......................3
How to handle a divorce ............................................1......................2......................3
How to handle grief and loss .....................................1 ....................2......................3
How to handle stress ..................................................1......................2......................3
How to manage a career .............................................1......................2......................3
How to manage money ..............................................1......................2......................3
How to manage time at home ....................................1......................2......................3
How to manage time at work .....................................1......................2......................3
How to stop smoking .................................................1......................2......................3
How to stay clean and sober ......................................1......................2......................3
Self-help Groups
Adult Children of Alcoholics .........................1......................2......................3
Alcoholics Anonymous ..................................1......................2......................3
Narcotics Anonymous ....................................1......................2......................3
Codependency ................................................1......................2......................3
(6)
If you were interested, when is it most convenient for you to attend one of these programs?
Before
lunch
(7)
During my
lunch hour
After
lunch
After
work
Weekends
Would you be more likely to attend one of these programs if:
Child care was provided.............................................Yes ..............No
It met once for 3 hours ...............................................Yes ..............No
It met once a week until done ....................................Yes ..............No
It included booklets and handouts..............................Yes ..............No
Finally, the following personal information will be very helpful for analyzing the results of
this survey.
(8)
What is your gender?
Male
(9)
To which group do you belong?
AfricanAmerican
(10)
Married
1
Separated
Divorced
Widowed
Other
3
4
5 or more
3
4
5 or more
2
At work, are you a supervisor or non-supervisor?
Non-supervisor
In what division do you work?
Administration
(15)
Native Other
American
2
1
Supervisor
(14)
Hispanic
How many teenage children live with you?
0
(13)
Asian
How many children 12 years old or younger live with you?
0
(12)
Anglo
What is your marital status?
Single
(11)
Female
Community
Facilities
Development
Services
Finance
Police/
Fire
Utilities
How many years have you worked for the city of Big Town?
Less than
1 year
1 to 3
years
4 to 7
years
8 to 10
years
11 to 20
years
Herbie Jones thanks you for your time and effort! Please return your completed
questionnaire in the envelope provided.
More than
20 years