Focus & Vitality Assessment

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Focus & Vitality Assessment

Please read the following consent form. When you agree to participate, you will be directed to the self-assessment

Sign in to Google to save your progress. Learn more

Description: The purpose of this self-assessment is to identify potential correlations between participant’s screen time usage and their job satisfaction and personal sense of vitality. Completing this online survey will take approximately ten to fifteen minutes. Your responses will be kept confidential. The survey questions allow you to assess your sleep, diet, exercise, and screen-time usage habits.We will keep your information confidential. If you have any questions about the research study, please contact Dr. Georgianna at sgeorgianna@gmail.com. *

Agree

Disagree

How old are you? *

What is your Gender? *

Female

Male

Other:

Do you identify as White, Black or African-American, American Indian or Alaskan Native, Asian, Native Hawaiian or other Pacific Islander, or another racial group? *

White or Caucasian

Black or African-American

American Indian or Alaskan Native

Native Hawaiian or Pacific Islander

Asian

Hispanic or Latino

Other:

What is your current employment status? *

Employed, full-time

Employed, part-time

Other:

Thank you for your interest in an assessment of your screen-time usage, vitality, and life and job satisfaction. Your identity will be kept strictly confidential. *

Reasonable safeguards have been taken to minimize potential risks, known and unknown, involved with taking a focusing assessment. You do not have to participate in this assessment if you do not want to. You can change your mind and discontinue filling out the questionnaire at any time without reason and without penalty. If you have any questions or concerns about this assessment or questions about your rights as an assessment taker, please contact Dr. Sibylle Georgianna at sgeorgianna@gmail.com. Reasonable safeguards have been taken to minimize potential risks, known and unknown, involved with this assessment. By clicking "yes", you agree to not file any claims against the researcher, research supervisor and affiliated organizations. I understand the material above.

Yes

No

How many hours of sleep do you usually get on a given work-night? *

How many hours of sleep do you usually get on weekends or other off-days? *

How many hours of sleep do you wish to get on any given night? *

How would you define the quality of your sleep? *

1:Very Low - 2:Low - 3:Decent - 4:High- 5:Excellent

1

2

3

4

5

Personal Sense of Vitality

Please answer the following 5 questions regarding your personal sense of vitality on a scale from 0 for N/A or Never to 4 for Very Frequently.

When working in an enclosed area, I regularly open windows or occasionally go outside for some fresh air. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I make sure that I work my cardiovascular system at least once a day. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I eat a balanced diet rich in fruit, vegetables and fruit juices. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

If I feel mentally fatigued, I take breaks so I can do exercise. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I take regular exercise to improve my fitness and physical performance. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

Vitality in the Workplace

Please answer the following 6 questions regarding your vitality in regards to occupational stress on a scale from 0 for N/A or Never to 4 for Very Frequently.

Even when my job is extremely demanding, I consistently take breaks to relax. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I am able to cope well with occupational stress because I practice sports regularly. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

If possible, I try to break up long periods of sitting with active exercise. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I have noticed that I am more productive when I consume less tobacco and alcohol. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

When unhealthy eating habits creep in, I try to combat these immediately. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I mostly drink water or fruit juice to quench my thirst. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

Vitality and Relaxation Methods

Please indicate how well the following 20 statements describe your personal encounter with the situations and emotional sensitivities in question.

I listen to my body feedback to recognize if I am being overworked and need a break. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I look at specific sources of information (e.g. blogs, books) to learn how to relax during the day. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I occasionally use light stretching exercises to relieve body tension. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I can recognize when I become tense and I know how to relax in response to the tension. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

When I am mentally-exhausted I take a break from my current tasks and go for a walk. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

If I am severely stressed-out, I make sure people do not put me under any more pressure. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

If a certain situation is stressing me out, I will write it down so that I can better approach the problem in the future. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I use practices and methods such as prayer, meditation, yoga, or Pilates to help me relax. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I always make sure to take breaks during tasks, even if they are highly demanding. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

When I experience panic attacks or severely stressful situations, I find it helpful to take deep, slow breaths. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

A long, hot bath helps me alleviate my anxiety and stress. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

If I am stressed out, I am able to switch off from the situation and shift my focus to relaxing. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

Music helps me calm down and relax when I am stressed out. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

When I am in a severely stressful situation, I find it helpful to take a break and drink tea or coffee with others. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

If I feel overworked, I know of specific locations where I can recover and relax. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I occasionally attend seminars, conferences, or courses on meditation practices. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I have an intuitive sense of how to relax when I have a large work load. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I take short naps to recover my senses before my work load becomes overwhelming. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

Over time, I have developed stress-management techniques that help me switch off and focus my attention on relaxing. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I use relaxation techniques when I become anxious or overworked. *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

ADD TYPE TEST

I am easily distracted *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I have difficulty sustaining attention span for most tasks in play, school, or work *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I have trouble listening when others are talking *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I have difficulty following through (procrastination) on tasks or instructions *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I have a difficult time keeping an organized area (room, desk, book bag, filing cabinet, locker, etc.) *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I have trouble with time, for example, frequently late or hurried, tasks take longer than expected, projects or homework are “last minute” or turned in late *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I have a tendency to lose things *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I make careless mistakes and have pay poor attention to detail *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I am forgetful *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I am restless or hyperactive *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I have trouble sitting still *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I am fidgety, in constant motion (hands, feet, body) *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I am considered noisy and have a hard time being quiet *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I act as if "driven by a motor" *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I talk excessively *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I am impulsive (don’t think through comments or actions before they are said or done) *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I have difficulties waiting for my turn *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

I interrupt or intrude on others (e.g., butts into conversations or games) *

0:N/A or Never - 1:Rarely - 2:Occasionally - 3:Frequently - 4:Very Frequently

0

1

2

3

4

Next

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy