Biographical Questionnaire

Please respond to the following questions by placing a check () after the appropriate response. If you do not find
an exact answer for your case, please choose the response closest to your case.

Current Area Of Assignment: _________

1. Age:
( ) Less than 25
( ) 26-35
( ) 36-45
( ) 46-55
( ) 56-65
( ) More than 65

2. Gender:
( ) Male ( ) Female

3. Marital Status:
( ) Single ( ) Married ( ) Separated ( ) Widowed

4. What is your highest educational preparation in nursing?

( ) L.P.N. ( ) A.D.N. ( ) Diploma
( ) B.S.N. ( ) M.S.N ( ) M.N.
( ) M.A.N. ( ) Doctorate

5. What is your current position in the hospital?

( ) Head Nurse ( ) Senior Nurse ( ) Junior Nurse
( ) Probationary Nurse ( ) Reliever Nurse

6. Which shift do you work most often?

( ) Morning (7-3)
( ) Morning (7-7)
( ) Afternoon (3-11)
( ) Nights (11-7)
( ) Nights (7-7)
( ) Other: _________

7. What is the usual length of your shift?

( ) 8 hours
( ) 10 hours
( ) 12 hours
( ) Other: _________

8. What is the average number of patients in your assignment?

( ) 1-3
( ) 4-6
( ) More than 6

9. How long have you worked at this hospital?

( ) Less than 6 months
( ) 6 months – 3 years
( ) 4-6 years
( ) 7-10 years
( ) More than 10 years