Template library · Assessments & screeners
Workload & Organizational Burnout Screen template
Assess workplace factors contributing to burnout risk.
Screen for organizational drivers of burnout
- 16 fields across 4 sections
- Included with MyWellOps
- Edit it, or save your own version
What’s in it
Assessment Details
- Client NameText
- Date of BirthDate
- Client ID / MRNText
- Date of AssessmentDate
- Clinician / CoachText
- Location / ModalityText
Organizational Factors
- 1. My workload is manageableChoice
- 2. I have control over how I do my workChoice
- 3. I receive adequate recognition for my workChoice
- 4. My workplace community feels supportiveChoice
- 5. My values align with my organization's valuesChoice
- 6. Workplace processes feel fairChoice
Notes
- Specific organizational stressors identifiedText
- Recommended accommodations or changesText
Signatures
- Clinician SignatureSignature
- Date signed (clinician)Date
When to use it
Use an assessment at the start of work to set a baseline, then repeat it at review points so you and the client can see what has changed.
How it works in MyWellOps
- Pick it from Documents.
- Send it to the client to complete, or fill it in together during a session.
- Each completed copy is kept on the client’s record, so earlier results are there to compare.
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