Return-to-Work Anxiety Self-Assessment

Return-to-Work Anxiety Self-Assessment
Reflect on your feelings and concerns about returning to the workplace with this confidential self-assessment.
Your Name (optional)
First NameLast Name
Email Address (optional, for follow-up)
example@example.com
How would you rate your current level of anxiety about returning to work?

1
2
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10
1 is No anxiety, 10 is Extremely anxious

Please indicate how much you agree with the following statements:

Rows	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
I feel nervous thinking about returning to work.
I worry about my health and safety at the workplace.
I am concerned about changes in workplace routines or policies.
I feel confident in my ability to cope with work-related stress.
I believe my employer will support my transition back to work.

Which of the following concerns you most about returning to work? (Select all that apply)
Other
How comfortable are you discussing your concerns about returning to work with your employer or supervisor?
What coping strategies or resources have you found helpful in managing your anxiety? (Select all that apply)
Other
How soon are you expected to return to work?
Would you like to request any of the following supports from your employer? (Select all that apply)
Other
Please share any additional comments or specific concerns you may have about returning to work.
Should be Empty:

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