Version: 01

QUESTIONNAIRE ON INTRA-OCCUPATIONAL August 2019

PSYCHOSOCIAL RISK FACTORS Page 1 of 8

ASSESSMENT DATE

COMPANY

BRANCH

AREA OF WORK

OCCUPATION

INSTRUCTIONS

This questionnaire on psychosocial factors seeks to know your opinion on some aspects of your family
and personal life.

We would be grateful if you could answer the following questions with absolute sincerity. The answers
you give in the questionnaire are neither good nor bad; what is important is that they reflect your thoughts
on the conditions of your family and personal life.

Your answers will be dealt with in absolute confidentiality.

It is very important that you answer all the questions and give only one answer to each.

Please read each question carefully and mark with an “X” the box that best reflects your way of thinking.
If you make a mistake in the answer, cross it out and write the correct one.

Example:

Almost Sometimes Almost

Always Never
always never

My home is comfortable X

Definitive answer / Mistaken answer

If you have doubts about any question, request further explanation from the person who gave you the
questionnaire.

The questionnaire has no time limit; however, you will need approximately 10 minutes to answer all the
questions.

Thank you for your collaboration.

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QUESTIONNAIRE ON INTRA-OCCUPATIONAL May 2017
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The following questions relate to various Almost Sometime Almost

Always Never
conditions of the area in which you live: always s never

It is easy for me to move between my home and

1 0 1 2 3 4
my work place
I have to use various means of transport to arrive
2 4 3 2 1 0
at my work place
3 I spend a lot of time travelling to and from work 4 3 2 1 0
4 I can move between my home and work in comfort 0 1 2 3 4
5 The area I live in is safe 0 1 2 3 4
There is theft and a lot of delinquency in the area I
6 4 3 2 1 0
live.
From where I live, it is easy for me to reach the
7 0 1 2 3 4
medical center where I am treated
8 The roads close to my home are in good condition 0 1 2 3 4
9 I can easily find transport close to my home 0 1 2 3 4
10 My home conditions are good 0 1 2 3 4
There are water and electricity services in my
11 0 1 2 3 4
home
My home conditions allow me to rest when I need
12 0 1 2 3 4
to
13 My home conditions allow me to feel comfortable 0 1 2 3 4

The following questions relate to your life outside Almost Sometime Almost
Always always s never Never
work:

14 I have enough time for leisure activities 0 1 2 3 4

15 I have enough time outside work to rest 0 1 2 3 4

16 I have time for personal and household matters 0 1 2 3 4
17 I have time to share with my family and friends 0 1 2 3 4
I have good communication with the people close
18 0 1 2 3 4
to me
19 My relationships with friends is good 0 1 2 3 4
I talk with the people close to me about various
20 0 1 2 3 4
topics
My friends are willing to listen to me when I have
21 0 1 2 3 4
problems
22 My family supports me when I have problems 0 1 2 3 4
I can talk with the people close to me about things
23 0 1 2 3 4
that happen to me
24 My personal or family problems affect my work 4 3 2 1 0

The following questions relate to your life outside Almost Sometime Almost
Always always s never Never
work (continuation):

25 I have a friendly relationship with my close family 0 1 2 3 4

My personal or family problems drain me of energy I
26 4 3 2 1 0
need for work
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QUESTIONNAIRE ON INTRA-OCCUPATIONAL May 2017
PSYCHOSOCIAL RISK FACTORS – FORM A Page 8 of 8

27 We solve problems within the family in a friendly way 0 1 2 3 4

28 My personal or family problems affect my
4 3 2 1 0
relationships at work
29 The money we earn in the household is enough to
0 1 2 3 4
cover our basic expenses
I have other financial commitments that greatly
30 4 3 2 1 0
affect the family budget
31 At home we have debts that are difficult to repay 4 3 2 1 0

MANY THANKS FOR YOUR COLLABORATION.