Name *

First Name

Last Name

Which of the following phases best describes where you are in your professional career? (Check more than one) *

In college or graduate school

Early career (0-5 years)

Mid-career (6-15 years)

Late career (16+ years)

Transitioning to a new job or career

Transitioning to retirement

Looking to start my own business or side hustle

Are you looking for information about *

Check all that apply.

physical health

mental health

nutrition

general wellbeing

other

Work-Life Balance *

Answer each item reflecting on how often you experience the statement on a scale from (1-5): 1 always, 2 often, 3 sometimes, 4 rarely, 5 never

I feel loyalty to my roles both in my professional life and my family

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I am successful at creating a balance between my multiple life roles (employee/spouse/mother, father, etc.)

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I can deal with the situations that occur due to the conflict between my roles that are specific to my professional and family life

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

My job produces strain that makes it difficult to fulfill family duties.

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Due to work-related duties, I have to make changes to my plans for family activities.

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

My home life interferes with my responsibilities at work such as getting to work on time, accomplishing daily tasks, and working overtime.

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Family-related strain interferes with my ability to perform job-related duties.

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Do you think of trying to leave your job everyday? *

Yes

No

Does your workplace provide you all the resources to execute your role successfully? *

Yes

No