PERSONAL DATA:
1. Name :
2. Employment Number:
3. Age: 20-30 31-40 41-50 51-60 Above 60 years
4. Sex: Male Female
5. Marital Status: Married Unmarried
6. Designation: Supervisor Staff Nurse
ANM Nurse Trainee
7. Educational Qualification: 1 year nurse training ANM
Diploma B.Sc., Nursing
8. Years of experience: 0-5years 5-10 years
10-15 years above 15 years
9. Monthly Income: 1000 4000 4001 7000
7001 10000 Above 10001
do
My income is enough to meet my life needs
Salary differentials is fairly calculated based
on responsibility of work
There is good linking of rewards and work
performance
Safe and Healthy Working Condition
I am provided with adequate supplies to
organization
There is no ill treatment of nurses by other
performance
Autonomy and Participation
I have been given adequate freedom to carry
implementation if reasonable
Adequacy of Resources
There is a balance between stated objectives
inpatient wards
Grievances Procedure
I know where to approach if I have any
complaint
My grievances are fairly enquired and
resolved
SIGNATURE :
DATE :