Employee Grief & Trauma Needs Assessment

Employee Grief & Trauma Needs Assessment

Thank you for inquiring into the services of Claire M. Schwartz & Miriam’s Well Healing LLC. This questionnaire will gather data and answers from your employees as to their experiences of losses and/or traumas. This plan and process will enable you to support them and yourself through any instance of Grief or Trauma. All responses are voluntary and will be gathered & be kept anonymously.
Grief & Loss
Have you ever experienced a death close to you?*

YesNoNot personally, but I have witnessed it in others.
How long ago was this?*

Within the last year1-3 years ago3-5 years ago5-10 years ago
Was this at this company or a previous employer?*

This companyA different company
How much Paid Bereavement Leave did you receive?*

1 day2 days3 days4 daysNone
Was that enough?*

YesNo
If not, how did you get more time off?*

Vacation TimeSick TimeFamily Medical Leave ActUnpaid LeaveI had to stop working
Please add whatever comments you think will provide clarity regarding time off
Type as long as you need, the space will expand.
How did your colleagues at work respond to your loss?*

Warm & CompassionateMade Uncomfortable CommentsChecked on me to see what I neededAsked Inappropriate QuestionsBehaved as though nothing had happened
Please add whatever comments you would like about your colleagues - this is confidential
Type as long as you need, the space will expand.
How did your supervisors at work respond to your loss?*

Warm & CompassionateMade Uncomfortable CommentsExpected me to work the same way I did prior to the lossChecked on me to see what I neededAsked Inappropriate QuestionsBehaved as though nothing had happened
Please add whatever comments you would like about your supervisors - this is confidential
Type as long as you need, the space will expand.
If the responses you received were negative, what emotions did that cause?

AngryResentfulHurtShockedConfusedScaredLike I wanted to quit
If the responses you received were positive, what emotions did that cause?

RelievedGratefulSurprisedLike I had found a homeIt made me want to get better because I felt so supported
Did you tell your friends and family how your workplace responded?*

YesNo
How did they react when you told them?
Type as long as you need, the space will expand.
During Your Leave
Which of these issues were you dealing with while you were away?*

Funeral ArrangementsTravel ArrangementsPhysical Health IssuesMental Health IssuesFinancial IssuesOther - please add details below
Type as long as you need, the space will expand.
Was the experience harder than you thought?*

Much harderSomewhat harderI knew it would be hard, but it got harder as I went through itIt was as hard as I expectedNo, it was easier than I expectedOther - please add details below
Type as long as you need, the space will expand.
What Life Traumas have you been through in your life that have affected you and were never acknowledged in your job?

DivorceDiagnosis or Serious IllnessAssaultCrime VictimDomestic ViolenceAccidentDrug or Alcohol IssuesOther
What immediate needs would you like to receive at the beginning of this support package?

Self-Care Advice for Mind, Body & SpiritWhat To Say/What Not To SayThe Ten Tall Tales of Grief & Loss
What other support options would be helpful? Do you have any additional questions?
Type as long as you need, the space will expand.
Thank you so much for your candor in answering these vital questions!

All your responses will be kept private and anonymous.

Should you wish to contact Claire privately, you can reach her at miriamswellhealing@gmail.com or YouCanHealYourGrief@gmail.com.
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Employee Grief & Trauma Needs Assessment

Grief & Loss

During Your Leave