Employee Workplace Trauma Screening Questionnaire Form
Please complete this form to help us understand your workplace trauma-related concerns. Your responses are confidential and will assist in providing appropriate support.
Full Name
*
First Name
Last Name
Job Title / Role
Have you experienced a distressing or traumatic event at your workplace?
*
Yes
No
If yes, how recently did the event occur?
Please Select
Within the past week
Within the past month
1–6 months ago
More than 6 months ago
Not applicable
What type of workplace event(s) did you experience? (Select all that apply)
Harassment or bullying
Violence or threat of violence
Accident or injury
Witnessing a traumatic event
Other
How often have you experienced the following since the event?
Rows
Never
Rarely
Sometimes
Often
Very Often
Intrusive thoughts or memories about the event
1
2
3
4
5
Avoiding reminders of the event
6
7
8
9
10
Feeling anxious or on edge at work
11
12
13
14
15
Difficulty sleeping or concentrating
16
17
18
19
20
Changes in mood (e.g., sadness, irritability)
21
22
23
24
25
On a scale of 1 to 10, how much has this experience affected your work performance?
No impact
1
2
3
4
5
6
7
8
9
Severe impact
10
1 is No impact, 10 is Severe impact
Have you sought or received any support for this concern?
Yes, from within the organization
Yes, from outside the organization
No
Prefer not to say
Please describe any additional details or concerns you would like to share (optional)
Submit
Should be Empty: