Contact
Information (providing information in this section is optional,
the information allows us to keep you
informed of future products and services that best meet your needs.) |
Name:
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Phone Number:
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Fax Number:
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Email:
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Street:
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City:
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State/Province:
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Country:
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Zipcode:
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Personal/Background
Information (providing information in this section is required,
this information allows us to contrast our data by various groupings.) |
Age: |
under 20
20-29
30-39
40-49
50-59
60 and over |
Position: |
hourly non-management
salaried non-management
bargain unit/union employee
lower level management
mid-level management
executive management |
Gender: |
male
female |
Ethnicity:
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caucasian
african american
asian
hispanic
native american
other |
Education:
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grade school |
Job
Details (providing information in this section is required.)
If your are currently retired or unemployed type "retired"
or "unemployed" in the Job Title box and "click" on the "Other" Industry
button below. |
Job Title: |
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Number of years in current position: |
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Industry Classification:
(Click on the
"radio button" that best describes your industry then select from the "pull
down" menu below it for the specific product or service that your company
produces.) |
Durable Goods Manufacturing:
Non-Durable Goods Manufacturing:
Utilities & Energy:
Retail & Wholesale Trade:
Services:
Banking & Finance:
Insurance:
Health Care:
Other Organizations:
Other : |
Annual Wage
Range: |
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Strongly
Agree |
Moderately
Agree |
No
Opinion |
Moderately
Disagree |
Strongly
Disagree |
1.
Is willing to share personal failures. |
SA |
MA |
NO |
MD |
SD |
2.Has a self assured bearing. |
SA |
MA |
NO |
MD |
SD |
3.
Maintains composure during times of stress, pressure or disagreement. |
SA |
MA |
NO |
MD |
SD |
4.
Takes the ball and runs with it, even when there are obstacles. |
SA |
MA |
NO |
MD |
SD |
5.
Tells the truth even when it is difficult. |
SA |
MA |
NO |
MD |
SD |
6.
Is respectful of other people even when there is nothing to gain from the relationship. |
SA |
MA |
NO |
MD |
SD |
7. Always does what he/she says he/she will do. |
SA |
MA |
NO |
MD |
SD |
8. Evades responsibility; blames policy or management. |
SA |
MA |
NO |
MD |
SD |
9. Understands the dynamics of the entire organization, not just his/her functional area. |
SA |
MA |
NO |
MD |
SD |
10. Experiments and takes risks even when there is a chance of failure. |
SA |
MA |
NO |
MD |
SD |
11. Under pressure, is confident he/she will figure out a solution. |
SA |
MA |
NO |
MD |
SD |
12. Remains calm even in situations when others get angry. |
SA |
MA |
NO |
MD |
SD |
13. Willing to address performance issues with others. |
SA |
MA |
NO |
MD |
SD |
14. Does not brag or name drop. |
SA |
MA |
NO |
MD |
SD |
15. Avoids unproductive confrontation between self and others. |
SA |
MA |
NO |
MD |
SD |
16. Rarely loses temper. |
SA |
MA |
NO |
MD |
SD |
17. Does not fault other people or departments when the "going gets tough." |
SA |
MA |
NO |
MD |
SD |
18. Cultivates relationships with other groups and functions. |
SA |
MA |
NO |
MD |
SD |
19. Is not afraid to try out new approaches to solving problems. |
SA |
MA |
NO |
MD |
SD |
20. Communicates excitement, enthusiasm, and passion for the company as a whole and its goals. |
SA |
MA |
NO |
MD |
SD |
21. Follows through on commitments. |
SA |
MA |
NO |
MD |
SD |
22. Does not exhibit a "us vs. them" mentality. |
SA |
MA |
NO |
MD |
SD |
23. Is straightforward and willing to say what he/she thinks. |
SA |
MA |
NO |
MD |
SD |
24. Is consistent in word and deed. |
SA |
MA |
NO |
MD |
SD |
25. Looks for a scapegoat in a crisis. |
SA |
MA |
NO |
MD |
SD |
26. Considers the impact of decisions on other departments and groups. |
SA |
MA |
NO |
MD |
SD |
27.Welcomes suggestions and feedback for improvement. |
SA |
MA |
NO |
MD |
SD |
28. Is able to manage anxiety in difficult situations (e.g. in giving a speech or giving unwanted feedback). |
SA |
MA |
NO |
MD |
SD |
29. Takes the initiative to get things done. |
SA |
MA |
NO |
MD |
SD |
30. Is willing to compromise on a decision when appropriate. |
SA |
MA |
NO |
MD |
SD |
31. Treats all company personnel as his or her equals. |
SA |
MA |
NO |
MD |
SD |
32. Shows genuine concern for others. |
SA |
MA |
NO |
MD |
SD |
33.Is not defensive when questioned about mistakes. |
SA |
MA |
NO |
MD |
SD |
34. Decisions are focused on what is good for the organization, not just what is good for his/her group. |
SA |
MA |
NO |
MD |
SD |
35. Considers the impact of decisions on all departments. |
SA |
MA |
NO |
MD |
SD |
36. Backs down when he or she ought to stand firm. |
SA |
MA |
NO |
MD |
SD |
37.Spends time fixing problems, not assigning blame. |
SA |
MA |
NO |
MD |
SD |
38. Listens attentively to what others have to say. |
SA |
MA |
NO |
MD |
SD |
39. Can understand others' points of view, including views of those who are different. |
SA |
MA |
NO |
MD |
SD |
40. Admits fault, when appropriate. |
SA |
MA |
NO |
MD |
SD |
41. Demonstrates confidence in his/her ability and judgment. |
SA |
MA |
NO |
MD |
SD |
42. Accepts responsibility for own actions. |
SA |
MA |
NO |
MD |
SD |
43.Shares information across the company. |
SA |
MA |
NO |
MD |
SD |
44.Is not afraid to try something again when he/she has failed at it before. |
SA |
MA |
NO |
MD |
SD |
45."Walks the talk" -- has strong values and lives by them. |
SA |
MA |
NO |
MD |
SD |
46. Helps people see how their job or effort contributes to the company's success. |
SA |
MA |
NO |
MD |
SD |
47. Resolves disagreements in an open and productive manner. |
SA |
MA |
NO |
MD |
SD |
Job Specific Questions:
Please answer the following questions as they apply to your position. |
1. Compared to your co-workers in your organization with your same job description, how do you rank in overall effectiveness? |
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2. Regardless of your feelings toward your organization,
Manager or coworkers, how satisfied are you with your job? |
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3. How many promotions and/or raises have you received since you started with your current organization? |
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4. During your last performance review, what kind of evaluation did you receive from your supervisor/Manager? |
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5. IF you are in SALES or involved in selling products/services: What percent of your job duties involves the selling of a product(s) or service(s)? |
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6. IF you are in SALES or involved in selling: How much do you enjoy selling products/services? |
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7. IF you are in a CUSTOMER SERVICE position or a position that involves interacting with customers: What percent of your job duties involves interacting directly with customers? |
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8. IF you are a MANAGER or SUPERVISOR: Compared to your peers in your organization at your position, how do your subordinates rank in productivity/effectiveness? |
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9. IF you are a MANAGER or SUPERVISOR: How well regarded or esteemed are you by your subordinates? |
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