1. Preamble Consent, Demographics, Intent to Leave and Open-Ended Questions

Preamble Consent:

Date: June 10, 2017

Dear Hospice or Palliative Social Worker:

You are being invited to participate in a research study by answering the attached survey about compassion satisfaction, burnout, secondary trauma and overall work satisfaction as you experience it in your work as a hospice or palliative social worker. There are no known risks for your participation in this research study. The information collected may not benefit you directly. The information learned in this study may be helpful to others. The information you provide will be used to describe compassion satisfaction, burnout and secondary traumatic stress among hospice and palliative social workers and determine what can be done to improve your work environment.  Your completed survey will be stored on a password-protected computer in a locked office at the University of Louisville. The survey will take approximately 30 minutes to complete.

Individuals from the University Of Louisville Department Of Medicine, the University of Louisville Kent School of Social Work, the Institutional Review Board (IRB), the Human Subjects Protection Program Office (HSPPO), and other regulatory agencies may inspect these records. In all other respects, however, the data will be held in confidence to the extent permitted by law. Should the data be published, your identity will not be disclosed.

Taking part in this study is voluntary. By completing this survey you agree to take part in this research study. You do not have to answer any questions that make you uncomfortable. You may choose not to take part at all. If you decide to be in this study, you may stop taking part at any time.

If you have any questions, concerns, or complaints about the research study, please contact: Alyssa Middleton, M.S.W. at (502) 629-7447 or Barbara Head, PhD at (502) 852-3014.

If you have any questions about your rights as a research subject, you may call the Human Subjects Protection Program Office at (502) 852-5188. You can discuss any questions about your rights as a research subject, in private, with a member of the Institutional Review Board (IRB). You may also call this number if you have other questions about the research, and you cannot reach the research staff, or want to talk to someone else. The IRB is an independent committee made up of people from the University community, staff of the institutions, as well as people from the community not connected with these institutions. The IRB has reviewed this research study.

If you have concerns or complaints about the research or research staff and you do not wish to give your name, you may call 1-877-852-1167. This is a 24-hour hotline answered by people who do not work at the University of Louisville.


Barbara Head PhD., CHPN, ACSW, FPCN and Alyssa Middleton, M.S.W.


* 1. I have read above consent form and agree to participation in this study

* 2. Age in years

* 3. Gender

* 4. Please indicate your race/ethnicity

* 5. What state do you live in?

* 6. How long have you worked for your current employer?  (years & months)

* 7. How long have you worked in hospice and palliative social work:  (years & months)

* 8. Social Work Education:

* 9. State Licensure:

* 10. Are you certified in hospice and palliative social work by NASW (Advanced Certification in Hospice and Palliative Social Work, ACHP-SW)?

* 11. Are you certified in oncology social work by AOSW (Oncology Social Work Certification, OSW-C)?

* 12. If not certified, please indicate the reason(s) why. Mark all that apply.

* 13. How many hours per week do you work?

* 14. Approximate annual salary:

* 15. What type of organization do you work for?

* 16. Overall, how satisfied are you with your job?

* 17. How likely is it that you will leave this job in the next year?

* 18. If you are somewhat or very likely to leave, will you:

* 19. How often do you think about quitting?

* 20. List the three things that cause you the most stress in your  job:

* 21. List the three top activities you do for your self-care and/or to deal with the stress of your job:

* 22. What is the most important thing your employer could do to improve your job satisfaction?