Age: _______

Year & Program: ________________

Work: ____________

Gender: _________

How satisfied are you with your income? (5 being the highest)

_1 _2 _3 _4 _5

Are you required to do overtime work?

_Yes

_No

Are you given ample resting period?

_Yes

_No

Rate your work environment in terms of healthiness (5 being the highest)

_1 _2 _3 _4 _5

List down problems encountered in your work place: (optional)

I have experienced instances of fatigue that has led to illness due to the added tasks from work along
with school work

_Yes

_No