Form No number No number No name

Employee Survey Instrument (Both Waves)

Form Approved

OMB No. _________

Exp. Date _________

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Rd NE, MS E-11, Atlanta, GA 30333; ATTN: PRA (0920-XXXX).

Please be sure that you are in a private location, so that no one can see your answers to the questions. The survey questions ask about your background, employment and training experiences, current work behavior, health, experiences with domestic violence, and perceptions of domestic violence and the workplace. Your answers will be kept in confidence and will only be seen by the authorized research staff at RTI International. No <company> personnel will be able to see your individual responses.

<Company> is committed to protecting the privacy of all survey participants.  Any responses and personal information collected through this voluntary survey will be used solely for data purposes and will indefinitely remain secure and confidential.  In addition, <company> will not attempt to discern the identity of respondents under any circumstances.  (If you have any questions or concerns regarding this privacy statement, please contact <company contact>)

Background Information

The first set of questions asks for some basic information about you.

B1. What is your gender?

• Male

• Female

B2. How old are you?

[drop down box: Under 18, 18-29, 30-39, 40-49, 50-59, 60-69, 70 or older]

[IfB2=Under 18] We’re sorry but the survey can only be completed by individuals who are at least 18 years old. Thank you for your interest in our study. We appreciate your time. [“Back” button displayed]

B3. How would you describe your race/ethnic background? Please check all that apply.

• White

• Black or African American

• Hispanic or Latino/Latina

• Asian

• Native Hawaiian or Other Pacific Islander

• American Indian or Alaska Native

• Other (specify) ____________________

B4. What is your marital status?

• Married (or in a domestic partnership)

• Divorced

• Widowed

• Separated

• Never married

B5. [If B4≠Married] Are you currently involved in a steady intimate relationship?

• Yes

• No

B6. Do you have any children (including biological children, legally adopted children, or stepchildren)?

• Yes

• No

B7. [If B6=yes] How many children do you have?

[drop down box: 1, 2, 3, 4, 5, 6, more than 6]

B8. [If B6=yes] Are any of your children under the age of 18?

• Yes

• No

B9. What is the highest level of school you have completed?

• high school diploma or GED

• Vocational or trade school graduate (certificate program)

• Some college but no degree

• Associate degree (2 year academic, technical, or occupational program)

• Four year college graduate

• Advanced degree (including masters, professional, or doctoral degrees)

You have finished 1 out of 5 sections of the survey. 

After you click “forward” to advance to the next section, you will not be able to go back and change your answers in this section.

Employment

The next set of questions asks about your employment history and current position.

Employment History/Stability

E1. How many different jobs have you had since you were 18?

[drop down box: 1, 2, 3, 4, 5, 6, 7, 8, 9,10 or more]

E2. Since you were 18, what is the longest consecutive period of time you have worked at one job?

[drop down box: Less than 6 months, 6 months to less than a year, 1 year to less than 2 years, 2 years to less than 5 years, 5 -10 years, more than 10 years]

E3. Since you were 18, what is the longest consecutive period of time you have been unemployed. Do not count any time on maternity or paternity leave, or time that you were a student.

[drop down box: Less than 3 months, 3-6 months, 6 months to less than a year, 1 year to less than 2 years, 2 years to less than 5 years, 5 -10 years, more than 10 years]

E4. Since you were 18, how many times have you ever been fired from a job?

[drop down box: 0,1, 2, 3, 4, 5, 6, 7, 8, 9,10 or more]

E5. Since you were 18, how many times have you ever quit a job?

[drop down box: 0,1, 2, 3, 4, 5, 6, 7, 8, 9,10 or more]

Unit/Division

E6. In what unit/division do you currently work?

[drop down box: a complete list of trainings offered by the Company will be inserted]

Job Type

E7. What type of work do you do?

[drop down box: administration, finance, retail, marketing, security, product development, other]

E8. Are you a salaried or hourly employee?

• Salaried

• Hourly

• Other

Benefits

E9. Are you eligible to receive health insurance coverage from your employer?

• Yes

• No

E10. Are you entitled to any fully paid leave, such as sick leave or vacation leave, from your employer?

• Yes

• No

Job Retention

E11. How long have you worked for [company name]?

[drop down box: less than 3 months, 3-5 months, 6-11 months, 12 -24 months, 2-5 years, more than 5 years]

E12. How likely is it that you will stop working for [company name] in the next year?

• Very likely

• Somewhat likely

• Somewhat unlikely

• Not at all likely

E13. How likely is it that you will actively look for a new job in the next year?

• Very likely

• Somewhat likely

• Somewhat unlikely

• Not at all likely

Absenteeism (from NHIS)

E14. During the past 12 months, that is since [date], about how many days did you miss a half day or more from work or business because of illness or injury? Do not include maternity or family leave.

[drop down box: 0, 1-2 days, 3-5 days, 5-9 days, 10-19 days, 20-29 days, 30-39 days, 40-49 days, 50 or more days]

Productivity/Presenteeism (from HPQ, items B8, B9-12)

E15. How many hours do you work in an average week?

[drop down box: Under 10, 10-19, 20-29, 30-39, 40-49, 50-59, 60-69, 70 or more]

E16. The next questions are about the time you spend during your hours at work in the past 4 weeks (28 days). Select the one response for each question that comes closest to your experience.	All of the time	Most of the time	Some of the time	A little of the time	None of the time
E16a. How often was your performance higher than most workers on your job?					
E16b. How often was your performance lower than most workers on your job?					
E16c. How often did you do no work at times when you were supposed to be working?					
E16d. How often did you find yourself not working as carefully as you should?					
E16e. How often was the quality of your work lower than it should have been?					
E16f. How often did you not concentrate enough on your work?					
E16g. How often did health problems limit the kind or amount of work you could do?					

E17. On a scale from 0 to 10 where 0 is the worst job performance anyone could have at your job and 10 is the performance of a top worker, how would you rate…

	0	1	2	3	4	5	6	7	8	9	10
E17a. the usual performance of most workers in a job similar to yours?											
E17b. your usual job performance over the past year?											
E17c. your overall job performance on the days you worked during the past 4 weeks (28 days)?											

E18. How would you compare your overall job performance on the days you worked during the past 4 weeks (28 days) with the performance of most other workers who have a similar type of job? (Select only one.)

• You were a lot better than other workers.

• You were somewhat better than other workers.

• You were a little better than other workers.

• You were about average.

• You were a little worse than other workers.

• You were somewhat worse than other workers.

• You were a lot worse than other workers.

Employee-Manager Interaction

E19. How often do you typically interact with your direct supervisor…

	Less than once a week	1-3 times a week	3-4 times a week	5-6 times a week	More than 6 times a week
E19a. in person?					
E19b. over the phone?					
E19c. through e-mail exchange?					

Perceptions of Manager Interest in Personal Life

E20. How often do you typically discuss matters other than work with your direct supervisor?

• Less than once a week

• 1-3 times a week

• 3-4 times a week

• 5-6 times a week

• More than 6 times a week

E21. How much do you feel that your direct supervisor cares about you as a person?

• Very much

• A little

• Not much

• Not at all

You have finished 2 out of 5 sections of the survey. 

After you click “forward” to advance to the next section, you will not be able to go back and change your answers in this section.

Health

Health-related Quality of Life (SF-12, Version 2.0)

Next, we would like your views about your health.

H1. In general, would you say that your health is:

• Excellent

• Very good

• Good

• Fair

• Poor

H2. The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

		Yes, limited a lot		Yes, limited a little		No, not limited at all
H2a. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf					
H2b. Climbing several flights of stairs					

H3. During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

	All of the time	Most of the time	Some of the time	A little of the time	None of the time
H3a. Accomplished less than you would like					
H3b. Were limited in the kind of work or other activities					

H4. During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?

	All of the time	Most of the time	Some of the time	A little of the time	None of the time
H4a. Accomplished less than you would like					
H4b. Did work or other activities less carefully than usual					

H5. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework?

• Not at all

• A little bit

• Moderately

• Quite a bit

• Extremely

H6. These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks…

	All of the time	Most of the time	Some of the time	A little of the time	None of the time
H6a. Have you felt calm and peaceful?					
H6b. Did you have a lot of energy?					
H6b. Have you felt downhearted and depressed?					

H7. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives, etc.)?

• All of the time

• Most of the time

• Some of the time

• A little of the time

• None of the time

Health Care Utilization (from NHIS)

H8. During the past 12 months, that is since [date], have you seen or talked to any of the following health care providers about your own health?

	Yes	No
H9a. A mental health professional such as a psychiatrist, psychologist, psychiatric nurse, or clinical social worker.		
H9b. [If B1=female] A doctor who specializes in women’s health (an obstetrician/gynecologist)		
H9c. A medical doctor who specializes in a particular medical disease or problem (other than obstetrician/gynecologist, psychiatrist, or ophthalmologist)		
H9d. A general doctor who treats a variety of illnesses (a doctor in general practice, family medicine, or internal medicine).		

H10. During the past 12 months, how many times have you gone to a hospital emergency room about your own health? This includes emergency room visits that resulted in a hospital admission.

[drop down box: None, 1, 2-3, 4-5, 6-7, 8-9, 10-12, 13-15, 16 or more]

H11. During the past 12 months, how many times have you seen a doctor or other health care professional about your own health at a doctor’s office, a clinic, or some other place? Do not include times you were hospitalized overnight, visits to hospital emergency rooms, home visits, dental visits, or telephone calls.

[drop down box: None, 1, 2-3, 4-5, 6-7, 8-9, 10-12, 13-15, 16 or more]

H12. During the past 12 months, have you contacted the [Company name] Employee Assistance Program (EAP) for help with grief and loss, stress, balancing work and family, depression and anxiety, communication breakdowns, financial difficulties, work-related issues, or alcohol or drug use/abuse?

• Yes

• No

You have finished 3 out of 5 sections of the survey. 

After you click “forward” to advance to the next section, you will not be able to go back and change your answers in this section.

Experiences

The next set of questions asks about violence between intimate partners. By “violence between intimate partners” we mean the use of physical, sexual, or emotional abuse or threats to control another person who is an intimate partner. Please remember that you do not have to answer any questions that you don’t want to. Also, remember that your responses to the survey questions will be kept completely confidential and will only be seen by the authorized research staff at RTI.

IPV Victimization and Perpetration (V1-20 are from CTS2-Short Form)

No matter how well a couple gets along, there are times when they disagree, get annoyed with the other person, want different things from each other, or just have spats or fights because they are in a bad mood, are tired, or for some other reason. Couples also have many different ways of trying to settle their differences. This is a list of things that might happen when you have differences. Please mark how many times you did each of these things in the past year, and how many times your partner did them in the past year. If you or your partner did not do one of these things in the past year, but it happened before that, mark “7” for that question. If it never happened, mark a “0”.

1 = once in the past year 5 = 11-20 times in the past year

2 = twice in the past year 6 = more than 20 times in the past year

3 = 3-5 times in the past year 7= None in the past year, but it did happen before

4 = 6-10 times in the past year 0 = This has never happened

In the past year, how often did this happen?	1	2	3	4	5	6	7	0
V1. I explained my side or suggested a compromise for a disagreement with my partner.								
V2. My partner explained his or her side or suggested a compromise for a disagreement with me.								
V3. I insulted or swore or shouted or yelled at my partner.								
V4. My partner insulted or swore or shouted or yelled at me.								
V5. I had a sprain, bruise, or small cut, or felt pain the next day because of a fight with my partner.								
V6. My partner had a sprain, bruise, or small cut, or felt pain the next day because of a fight with my partner.								
V7. I showed respect for, or showed that I cared about my partner’s feelings about an issue we disagreed on.								
V8. My partner showed respect for, or showed that I cared about my partner’s feelings about an issue we disagreed on.								
V9. I pushed, shoved, or slapped my partner.								
V10. My partner pushed, shoved, or slapped me.								
V11. I punched or kicked or beat up my partner.								
V12. My partner punched or kicked or beat-me-up.								
V13. I destroyed something belonging to my partner or threatened to hit my partner.								
V14. My partner destroyed something belonging to me or threatened to hit me.								
V15. I went to see a doctor (M.D.) or needed to see a doctor because of a fight with my partner.								
V16. My partner went to see a doctor (M.D.) or needed to see a doctor because of a fight with me.								
V17. I used force (like hitting, holding down, or using a weapon) to make my partner have sex.								
V18. My partner used force (like hitting, holding down, or using a weapon) to make me have sex.								
V19. I insisted on sex when my partner did not want to or insisted on sex without a condom (but did not use physical force).								
V20. My partner insisted on sex when I did not want to or insisted on sex without a condom (but did not use physical force).								

[Display the following in a bulleted list above V21: “ your partner pushed, shoved, or slapped you”; “your partner punched or kicked or beat you up”; “your partner destroyed something belonging to you or threatened to hit you”; “you went to see a doctor or needed to see a doctor because of a fight with your partner”; “you had a sprain, bruise, or small cut, or felt pain the next day because of a fight with your partner”; “your partner used force (like hitting, holding down, or using a weapon) to make you have sex”; “your partner insisted on sex when you did not want to or insisted on sex without a condom (but did not use physical force)”]

V21. [If V5, V10, V12, V14, V16, V17, OR V20 > 1] Have you ever experienced any of the things on the list above from an intimate partner while employed by [company name] or any of its subsidiaries or affiliates?

• Yes

• No

Perceived Impact of Victimization on Work (modified from Company’s Survey)

V22. [If V5, V10, V12, V14, V16, V17, OR V20 > 1] How did these experiences affect your ability to work?

• Significantly

• Somewhat

• Minimally

• No effect

V23. [If V5, V10, V12, V14, V16, V17, OR V20 > 1] Below is a list of the various ways these experiences might have affected you in the workplace. Please choose all that apply.

• Missed days

• Lateness

• Distraction

• Inability to complete assignments on time

• Need to seek out co-workers for additional help

• Problems with your boss

• Problems with other co-workers

• Job loss

• Fear of discovery

• Fear of intimate partner’s unexpected visits

• Harassment by intimate partner at work (either by phone or in person)

Utilization of Company DV Resources (from Company’s Survey, victims only)

V24. [If V21=Yes] Did you inform anyone from [company name] that you were experiencing domestic violence?

• Yes

• No

• Not sure

V25. [If V24=Yes] Who did you contact? Please check all that apply.

• A co-worker

• The person who is currently you direct supervisor/manager

• A supervisor or manager who is not your current supervisor/manager

• A human resources (HR) staff member

• A representative from the Company’s Employee Assistance Program (EAP)

• A security staff member

• Someone else (please specify: ___________________________)

V26. [If V24=Yes] What sorts of programs or support did the Company offer to help? Please check all that apply.

• Providing access to counseling and assistance

• Providing information and referral to domestic violence programs

• Contacting authorities

• Providing security services to you (e.g., escorting you to your car, providing you with a pager or cell phone, switching your office location)

• Providing access to legal support

• Providing flexible leave time or other benefits

• Other (please specify: ________________________)

V27. [If V24=No] What prevented you from informing the Company that you were experiencing domestic violence? Please check all that apply.

• You did not think it was a serious enough problem to report

• You were embarrassed to have people at work know about the problem

• You were afraid of hurting your reputation at work

• You were afraid of what your coworkers would think

• You felt that domestic violence is not a work issue

• You were afraid that your manager/supervisor would think less of you

• You felt that your manager/supervisor would not understand what domestic violence has to do with work

• You were afraid of retaliation by your spouse/partner

• Other (please specify: ________________________)

Satisfaction with Company DV Resources (victims only)

V28. [If V24=Yes] How helpful did you find the program or resources offered by the Company?

• Extremely helpful

• Very helpful

• Somewhat helpful

• Not helpful

V29. [If response options 2 OR 3 were selected for V25] How supportive was the manager/supervisor when you told them you had experienced violence from an intimate partner?

• Very supportive

• Somewhat supportive

• Not very supportive

• Not at all supportive/hostile

V30. [If response options 4, 5, OR 6 were selected for V25] How supportive were Company officials when you told them you had experienced violence from an intimate partner?

• Very supportive

• Somewhat supportive

• Not very supportive

• Not at all supportive/hostile

V31. [If response option 1 was selected for V25] How supportive were your co-workers when you told them you had experienced violence from an intimate partner?

• Very supportive

• Somewhat supportive

• Not very supportive

• Not at all supportive/hostile

Hypothetical use of Company IPV Resources (non-victims only)

V32. [If V5, V10, V12, V14, V16, V17, AND V20 = 0] If you were to experience violence from an intimate partner, how likely is it that you would tell your manager/direct supervisor?

• Very likely

• Somewhat likely

• Somewhat unlikely

• Not at all likely

V33. [If V5, V10, V12, V14, V16, V17, AND V20 = 0] If you were to experience violence from an intimate partner, how likely is it that you would tell a co-worker at the company?

• Very likely

• Somewhat likely

• Somewhat unlikely

• Not at all likely

V34. [If V5, V10, V12, V14, V16, V17, AND V20 = 0] If you were to experience violence from an intimate partner, how likely is it that you would tell someone else at [company name], such as a human resources (HR) staff member, a representative from the Employee Assistance Program (EAP), or a security staff member?

• Very likely

• Somewhat likely

• Somewhat unlikely

• Not at all likely

You have finished 4 out of 5 sections of the survey. 

After you click “forward” to advance to the next section, you will not be able to go back and change your answers in this section.

Domestic Violence and the Workplace

The next set of questions asks more about your awareness of [company name]’s domestic violence program.

Awareness of the Company’s Domestic Violence Program

D1. How seriously do you believe [company name] takes the issue of domestic violence and its impact on the workplace?

• Not seriously

• Somewhat seriously

• Very seriously

• Extremely seriously

D2. Are you aware if [company name] has a workplace program for people experiencing violence from an intimate partner?

• Yes

• No

D3. [If D2=Yes] How effective do you believe [company name]’s program is?

• Very effective

• Somewhat effective

• Not very effective

• Not effective at all

Attitudes toward Domestic Violence as a Workplace Issue

D4. In general, how much do you agree or disagree that it is important for companies to provide services for employees who are experiencing domestic violence?

• Strongly agree

• Agree

• Neither agree nor disagree

• Disagree

• Strongly disagree

 D5. How important is a manager’s role in supporting individuals experiencing domestic violence compared to other possible sources of support (such as family, friends, community organizations and neighbors)?

• More important

• Equally important

• Less important

Perception of Manager’s Attitudes toward Domestic Violence as a Workplace Issue

D6. In general, how much do you think your direct supervisor agrees or disagrees that it is important for companies to provide services for employees who are experiencing domestic violence?

• Strongly agree

• Agree

• Neither agree nor disagree

• Disagree

• Strongly disagree

D7. If you were experiencing violence by an intimate partner, how likely do you believe your direct supervisor would be to offer help?

• Very likely

• Somewhat likely

• Somewhat unlikely

• Not at all likely

You have finished all 5 sections of the survey.   Thank you very much for your participation.  Click “forward” to receive your survey completion code. 

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