Productivity & Burnout Index (PBI)
Name
First Name
Last Name
Department
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Administration
Finance
Development
Human Resources
Health and Wellness
Information Technology (IT)
Sales
Marketing
Production
Customer Service
Education
Research and Development (R&D)
Legal
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Design and Creative Arts
Engineering
Project Management
Consulting
Quality Assurance and Control
Manufacturing
Real Estate
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Hospitality and Tourism
Environmental and Green Technologies
Non-Profit and Social Services
Government and Public Administration
Media and Communication
Healthcare (distinct from Health and Wellness)
Pharmaceuticals
Biotechnology
Transportation and Warehousing
Energy and Utilities
Agriculture and Forestry
Mining and Extraction
Arts and Entertainment
Science and Technology
Sports and Recreation
Food and Beverage Services
Construction and Building
Automotive Industry
Aviation and Aerospace
Maritime and Naval
Business Name/Job Title
Work Environment
Please Select
Office-based
Remote
Hybrid
Other
Please select today's date.
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Please Select
Male
Female
Non-binary
Prefer not to answer
Productivity: How would you rate your level of productivity now?
Very Poor
1
2
3
4
Excellent
5
1 is Very Poor, 5 is Excellent
Burnout: How would you rate your degree of burnout now?
None
1
2
3
4
Very High
5
1 is None, 5 is Very High
Task Management: How effectively do you manage your daily tasks?
Not effective
1
2
3
4
Very effective
5
1 is Not effective, 5 is Very effective
Time Management: How often do you complete your work tasks within the allocated time?
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Focus and Concentration: How frequently do you find yourself getting distracted during work hours?
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Emotional Exhaustion: How often do you feel emotionally drained from your work?
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Depersonalization: Do you often find yourself feeling disconnected from your work?
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Work-Life Balance: How satisfied are you with your current work-life balance?
Very Dissatisfied
1
2
3
4
Dissatisfied
5
1 is Very Dissatisfied , 5 is Dissatisfied
Quality of Sleep: Rate the quality of your sleep on a typical night
Very Poor
1
2
3
4
Excellent
5
1 is Very Poor , 5 is Excellent
Quality of Diet: Rate the quality of your eating habits on a typical day
Very Poor
1
2
3
4
Excellent
5
1 is Very Poor, 5 is Excellent
Fitness: How often do you exercise currently (in number of days per week)?
1
2
3
4
5
6
7
1 is , 7 is
Current Stress Level: On a scale of 1-10, how would you rate your typical stress level?
None
1
2
3
4
5
6
7
8
9
High Stress
10
1 is None, 10 is High Stress
Motivation Factors: What factors most motivate you to be productive at work?
Self-Evaluation: How do you currently manage challenges related to productivity?
Burnout Symptoms: Describe any symptoms of burnout or excessive stress you have experienced
Self-Evaluation: How do you currently manage challenges related to burnout?
Productivity Challenges: What are the biggest challenges you face in being productive?
Video upload of reflection on this challenge (i.e. how this challenge impacted/influenced your day-to-day habits & productivity, difficult parts, easy parts, what your next steps may be after this to continue to grow, etc).
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