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- Do you identify as a woman?*
- Do you identify as Black?*
- Race*
- Ethnicity / Cultural Background (Select all that apply)*
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- Family / Household Composition (Select all that apply)*
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- What is your current employment status? (Select all that apply)*
- What level do you identify with?*
- Occupation Industry:*
- What is your current work requirement?*
- How long have you been in your current / previous position?*
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- How many hours do you typically work a day?*
- How often do you take breaks away from your desk?*
- At work, how often do you feel pressure to “push through” even when tired or unwell?*
- Do you feel supported by leadership when it comes to your mental and physical well-being?*
- How would you describe the level of diversity on your current team or within your organization?*
- How would you describe Black women’s representation on your team within your organization?*
- Have you experienced microaggressions or biased perceptions at work that affected your performance or well-being?*
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- How would you describe the overall emotional climate of your workplace? (Select all that apply)*
- Have you ever taken a mental health or wellness leave from work? (not including personal PTO or sick days)*
- Have you utilized your PTO or sick days for mental health reasons?*
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- Do you feel supported by leadership when it comes to advancing within your organization? (promotion, compensation increase, and development)*
- How often do you meet with your manager / supervisor / superior to discuss your performance, development, and advancement within the organization? (Not a formal performance review, this could be a 1:1)*
- Do you feel your formal performance reviews accurately reflect your contributions and impact?*
- In the past 12 months, have you taken on responsibilities beyond your initial job description? (Select all that apply)
- Were the additional responsibilities recognized with a compensation increase (raise, bonus) or a title change?*
- If you were not compensated or promoted for added responsibilities, how did that experience affect you? (Select all that apply)
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- Do you feel your compensation has kept pace with your growing experience, and responsibilities?*
- Have you asked / applied for a promotion or raise in the last 12 months?*
- If you asked or applied and were denied, what feedback (if any) were you given? (Select all that apply)
- Have you ever witnessed a less qualified colleague — particularly a non-Black woman — advance ahead of you?
- In the next 12 months, how likely are you to seek a promotion, raise, or greater responsibilities within your current organization?*
- In the next 12 months, how likely are you to pursue employment opportunities outside your current organization?*
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- How often do you feel physically or mentally drained by the end of your day?*
- What are your top sources of stress? (check all that apply)*
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- What are the first signs or symptoms you notice that let you know you're stressed? (Select all that apply)*
- Have you been diagnosed with a stress-related condition since starting your role? (Select all that apply)*
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- Has your relationship with food changed since entering your current profession or workplace?*
- How often do you eat during work activities (emails, meetings, calls)?*
- When you’re stressed, how does it affect your eating habits?*
- Do you feel you have time to eat intentionally and without distraction during your workday?*
- Have you ever used food as a way to cope with work-related stress, reward yourself after a difficult day, or comfort yourself during a hard season at work?*
- Do you plan or prep meals for your work week?*
- How would you describe your water intake / hydration habits?*
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- Do you currently have health insurance coverage?*
- Have you ever ignored or delayed addressing a health concern because you didn't feel you could take time away from work?*
- Have you ever declined follow-up medical appointments due to work demands?*
- How often do you visit your primary care clinician for an annual physical?*
- Do you visit other specialists? (OB/GYN, dentist, therapist, etc.)*
- When you do seek medical care, how often do you feel you have to advocate for yourself to get solutions/treatments?*
- Have you ever had to switch your medical team or primary clinician because you felt dismissed, gaslit, or not taken seriously?*
- Have you ever been told your symptoms were stress-related by a clinician without further investigation?
- How do you typically manage your medical concerns and symptoms?*
- What barriers, if any, prevent you from seeking medical care? (Select all that apply)*
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- How would you describe the quality of your sleep?*
- How often do you move your body (walking, workouts, stretching)?*
- Which wellness practices are currently part of your routine? (Select all that apply)*
- How often do you engage in something purely for pleasure or enjoyment?*
- How often does financial stress compound your overall sense of wellbeing?*
- Which parts of yourself get neglected because of work? (Select all that apply)*
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- How often do you feel you are carrying the emotional labor of representing Black women in your workplace? (managing others' perceptions, being the only one in the room, feeling responsible for how your community is seen)*
- Do you code-switch at work — meaning, do you adjust your language, appearance, energy, or behavior to feel more accepted or taken seriously in your professional environment?*
- Outside of work, how often do you experience genuine joy, pleasure, or a sense of self that feels fully your own?
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- What kind of wellness support does your workplace offer? (Select all that apply)*
- What kind of wellness support do you wish your workplace offered? (Select all that apply)*
- If you had full access to wellness support designed specifically for Black women, what would you want it to address first? (Select up to 5)
- How likely are you to invest in personal wellness (nutrition, hormonal health, stress management) coaching or a wellness network in the next 3 months?*
- What type of wellness resource feels most approachable to you? (Select all that apply)*
- What would make you more likely motivate you to invest in your well-being? (Select all that apply)*
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