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* 1. In which province/territory do you practice dental assisting?

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* 2. What is your gender?

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* 3. What is your age?

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* 4. If you are currently unemployed, is the cause of your unemployment due to mental health illness or issues?

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* 5. If you are currently unemployed, is the cause of your unemployment due to physical health issues?

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* 6. What type of dental practice do you work in?

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* 7. How would you best describe your current employment? (select all that apply)

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* 8. Have you experienced any changes in your employment due to mental health illness or issues (including stress)?

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* 9. How often do you find your work stressful?

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* 10. Do you have access to stress management or stress reduction programs at your current workplace?

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* 11. How satisfied would you say you are with your job?

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* 12. I find there are not enough people or staff to get all the work done.

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* 13. I feel I have job security at my current place of employment.

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* 14. How likely is it that you will seek a new job with another employer within the next year (12 months)?

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* 15. Do you feel your mental health status is in any way attributed to discrimination you have experienced in your current job?

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* 16. Please indicate how much you agree or disagree with the following statements on your quality of dental assisting work life.

  Strongly Agree Agree Disagree Strongly Disagree
My job lets me use my skills and abilities
I have too much work to do everything well
At the place where I work, I am treated with respect
I trust the management at the place where I work
The safety of team members is a high priority of management where I work
There are no significant compromises or shortcuts taken when worker safety is at stake

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* 17. For each statement, indicate the frequency that corresponds to how you feel.

  Never A few times a year Once a month A few times a month Once a week A few times a week Every day
I feel emotionally drained by my work.
Working with people all day long requires a great deal of effort.
I feel like my work is breaking me down.
I feel frustrated by my work.
I feel I work too hard at my job.
It stresses me too much to work in direct contact with people.
I feel like I am at the end of my rope.

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* 18. For each statement, indicate the frequency that corresponds to how you feel.

  Never A few times a year Once a month A few times a month Once a week A few times a week Every day
I feel I look after certain patients impersonally, as if they are objects.
I feel tired when I get up in the morning and have to face another day at work.
I have the impression that my patients make me responsible for some of their problems.
I am at the end of my patience at the end of the work day.
I really don't care about what happens to some of my patients.
I have become more insensitive to people since I've been working.
I'm afraid that this job is making me uncaring.

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* 19. For each statement, indicate the frequency that corresponds to how you feel.

  Never A few times a year Once a month A few times a month Once a week A few times a week Every day
I accomplish many worthwhile things in this job.
I feel full of energy.
I am easily able to understand what my patients feel.
I look after my patients problems very effectively.
Through my work, I feel that I have a positive influence on people.
I am easily able to create a relaxed atmosphere with my patients.
I feel refreshed when I have been close to my patients at work. 
The following questions ask about how you have been feeling during the past 30 days. For each question, please check the item that best describes how often you had this feeling.

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* 20. During the past 30 days, approximately how often did you feel...

  All of the time Most of the time Some of the time A little of the time None of the time
nervous?
hopeless?
restless or fidgety?
so depressed that nothing could cheer you up?
that everything was an effort?
worthless?

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* 21. The six feelings in Question #21 asked about feelings that might have occurred during the past 30 days.  Taking them altogether, did these feelings occur more or less often than is usual for you? (NOTE: If you responded "None of the Time" for ALL SIX feelings in Question #21, respond "About the same as usual" to this question)

The next few questions are about how the feelings in Question #21 may have affected you in the past 30 days.  

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* 22. (NOTE: If you answered "None of the Time" to ALL SIX feelings in Question #21 DO NOT ANSWER THIS QUESTION)

During the past 30 days, how many days out of 30 were you totally unable to work or carry out your normal activities because of the six feelings in Question #21? )

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* 23. (NOTE: If you answered "None of the Time" to ALL SIX feelings in Question #21 DO NOT ANSWER THIS QUESTION) Excluding the number of days your reported in the previous, how many additional days in the past 30 were you able to do only half or less of what you normally do as a result of the six feelings in Question #21?

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* 24. (NOTE: If you answered "None of the Time" to ALL SIX feelings in Question #21 DO NOT ANSWER THIS QUESTION) During the past 30 days, how many times did you see a doctor or other health professional about the six feelings in Questions #21?

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* 25. (NOTE: If you answered "None of the Time" to ALL SIX feelings in Question #21 DO NOT ANSWER THIS QUESTION) During the past 30 days, how often have physical health issues been the main cause of the six feelings in Question #21

The next set of questions are about how you feel, and how things have been for you during the past 4 weeks.  If you are not sure which answer to select, please choose the one answer that comes the closest to describing you. 

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* 26. During the past 4 weeks, how much of the time ....

  All of the time Most of the time A good bit of time Some of the time A little of the time None of the time
...has your daily life been full of things that were interesting to you?
...have you felt depressed?
... have you felt loved and wanted?
...have you felt very nervous?
...have you been in control of your behavior?
...have you been in control of your thoughts, emotions and feelings?
...have you felt tense or high-strung?
...have you felt calm and peaceful?
...have you felt downhearted and blue?

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* 27. During the past 4 weeks, how much of the time....

  All of the time Most of the time A good bit of time Some of the time A little of the time None of the time
...were you able to relax without difficulty?
...have you felt restless, fidgety or impatient?
...have you been moody, or brooded about things?
...have you felt cheerful, light-hearted?
...have you been in low or very low spirits?
...were you a happy person?
...did you feel you had nothing to look forward to?
...have you felt so down in the dumps that nothing could cheer you up?
...have you been anxious or worried?

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* 28. If you would like to share any additional information about your experience, please use the space below.

THANK YOU FOR PARTICIPATING IN THIS STUDY!

As a reminder, this is a national survey examining mental health and the impact of work environments on dental assistants within Canada. 

The survey results will be analyzed and a summary report will be provided to all members of the Canadian Dental Assistants Association (CDAA).

Should you feel any discomfort after completing this survey, please contact your local health services for support. 

If you have any questions regarding the study, please contact the Executive Director of the CDAA at skavanagh@cdaa.ca
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