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* 1. Unique ID - Choose a unique identifier to track your results

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* 2. Enter an Email Address for Personalized Summary of Results

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* 3. Age

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* 4. Gender

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* 5. Location

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* 6. City/State

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* 7. Are you currently in Medical School?

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* 8. If in Medical School, indicate which year.

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* 9. Are you currently in Residency?  If so, indicate year of training.

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* 10. If you have completed training, how many years post-training/residency?

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* 11. Have you sought previous burnout treatment?

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* 12. If previous treatment, was this Personal Treatment? For example, care you sought for yourself.

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* 13. If previous treatment, was this Employer, Group , Institution or Physician Health Program Treatment? For example, this would be care that was provided by your employer.

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* 14. Type of Treatment - Check all that apply

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* 15. Duration of Therapy - Check all that apply

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* 16. What was your personal assessment of the success of your treatment?

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* 17. If you wanted treatment, but did not pursue it, why? Check all that apply

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* 18. Which clinical activities do you think contribute to your burnout?  Check all that apply.

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* 19. What Non-Clinical activities do you think contribute to your burnout? Check all that apply.

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* 20. Maslach Burnout Inventory - Section A

MBI - Human Services Survey for Medical Personnel - MBI-HSS (MP): Copyright ©1981, 2016 Christina Maslach & Susan E. Jackson. All rights reserved in all media. Published by Mind Garden, Inc., www.mindgarden.com

  Never A few times per year Once a month A few times per month Once a week A few times per 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’m at the end of my rope.

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* 21. Maslach Burnout Inventory - Section B

  Never A few times per year Once a month A few times per month Once a week A few times per week Every day
I feel I look after certain patients/clients 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/clients make me responsible for some of their problems.
I am at the end of my patience at the end of my work day.
I really don’t care about what happens to some of my patients/clients.
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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* 22. Maslach Burnout Inventory - Section C

  Never A few times per year Once a month A few times per month Once a week A few times per 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/clients feel.
I look after my patients’/clients’ problems very effectively.
In my work, I handle emotional problems very calmly
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/clients.
I feel refreshed when I have been close to my patients/clients at work.

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* 23. Would you like to be included on our email list for further information?

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* 24. If Yes, then please add email address for contact.

 
 100% of survey complete.

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