Please answer the following questions concerning your job by circling the number that best fits your situation.

		Very much so	Moderately so	Somewhat	Not at all
1	I have an extremely large amount of work to do	1	2	3	4
2	I can’t complete work in the required time	1	2	3	4
3	I have to work as hard as I can	1	2	3	4
4	I have to pay very careful attention	1	2	3	4
5	My job is difficult in that it requires a high level of knowledge and technical skill	1	2	3	4
6	I need to be constantly thinking about work throughout the working day	1	2	3	4
7	My job requires a lot of physical work	1	2	3	4
8	I can work at my own pace	1	2	3	4
9	I can choose how and in what order to do my work	1	2	3	4
10	I can reflect my opinions on workplace policy	1	2	3	4
11	My knowledge and skills are rarely used at work	1	2	3	4
12	There are differences of opinion within my department	1	2	3	4
13	My department does not get along well with other departments	1	2	3	4
14	The atmosphere in my workplace is friendly	1	2	3	4
15	My working environment is poor (e.g. noise, lighting, temperature, ventilation)	1	2	3	4
16	This job suits me well	1	2	3	4
17	My job is worth doing	1	2	3	4

Please answer the following questions concerning your health during the past month by circling the number that best fits your situation.

	Almost never	Sometimes	Often	Almost always
18. I have been very active	1	2	3	4
19. I have been full of energy	1	2	3	4
20. I have been lively	1	2	3	4
21. I have felt angry	1	2	3	4
22. I have been inwardly annoyed or aggravated	1	2	3	4
23. I have felt irritable	1	2	3	4
24. I have felt extremely tired	1	2	3	4
25. I have felt exhausted	1	2	3	4
26. I have felt weary or listless	1	2	3	4
27. I have felt tense	1	2	3	4
28. I have felt worried or insecure	1	2	3	4
29. I have felt restless	1	2	3	4
30. I have been depressed	1	2	3	4
31. I have thought that doing anything was a hassle	1	2	3	4
32. I have been unable to concentrate	1	2	3	4
33. I have felt gloomy	1	2	3	4
34. I have been unable to handle work	1	2	3	4
35. I have felt sad	1	2	3	4
36. I have felt dizzy	1	2	3	4
38. I have experienced headaches	1	2	3	4
39. I have had a stiff neck and / or shoulders	1	2	3	4
40. I have had lower back pain	1	2	3	4
41. I have had eyestrain	1	2	3	4
42. I have experienced heart palpitations or shortness of breath	1	2	3	4
43. I have experienced stomach and / or intestine problems	1	2	3	4
44. I have lost my appetite	1	2	3	4
45. I have experienced diarrhea and / or constipation	1	2	3	4
46. I haven’t been able to sleep well	1	2	3	4

How freely can you talk with the following people?		Extremely	Very much	Somewhat	Not at all
47	Superiors	1	2	3	4
48	Co-workers	1	2	3	4
49	Spouse, family, friends, etc.	1	2	3	4

How reliable are the following people when you are troubled?
50	Superiors	1	2	3	4
51	Co-workers	1	2	3	4
52	Spouse, family, friends, etc.	1	2	3	4

How well will the following people listen to you when you ask for advice on personal matters?
53	Superiors	1	2	3	4
54	Co-workers	1	2	3	4
55	Spouse, family, friends, etc.	1	2	3	4

		Satisfied	Somewhat satisfied	Somewhat dissatisfied	Dissatisfied
56	I am satisfied with my job	1	2	3	4
57	I am satisfied with my family life	1	2	3	4

＊職業性ストレス簡易調査票（57 項目）英語版　厚生労働省データより

Please contact BuonVento for a stress check evaluation.