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Work-Site Organizational Health Survey (Sample)

Name of Work Group: _______________________________

Address:
City:
State:
Zip:

Name of Respondent: __________________________

Title/Function: _______________

Phone Number: (_ _ _) _ _ _ - _ _ _ _

Email: _________________________________

Physical Activity

What types of facilities or resources does your organization provide for employees to engage in physical activity? 
Please tell us if your organization offers the following resources.

1.  Does your worksite have a place for employees to go for a walk?

a. If yes, can employees walk:

Indoors ____________

Outdoors ____________

b. If yes, is this place: (“X” all that apply)

Well Lit ____________

Safe from traffic, cars & machinery ____________

Secure from intruders ____________

Well ventilated ____________

Attractive ____________

2.  Does your organization have organized physical activities for employees?

3.  Does your organization have access to physical activity facilities for employees?
(such as basketball courts, walking trails)

4.  Does your organization have access to an indoor exercise facility?

a.  If yes, what equipment does it provide: (“X” all that apply)
Bikes, stair climbers, treadmills ….

Running track ____________

Swimming pool ____________

Strength training equipment ____________

Other _______________________

b.  When is the exercise facility open?  (“X” all that apply)

Before work hours ____________

After work hours ____________

During work hours ____________

c.  Is the facility free or discounted to employees?

d.  Can family members of employees use the facility?

5.  Does your organization subsidize memberships to off-site physical activity
facilities?

6.  Does your organization have stairs that employees can use for physical activity?

7.  Does your organization provide any incentives or rewards to employees who are physically active?

8.  Does your organization offer a health plan which provides discounts for health
club membership?

Nutrition

9.  Can employees in your organization obtain food or snacks at the workplace?

If No, please skip to question #12.

10.  Where are the foods or snacks offered? (“X” all that apply)

Break room or company kitchen ____________

Canteen truck/snack bar ____________

Vending machines ____________

Caterer ____________

Other: (describe) ____________

11.  If your organization has vending machines, what types of food are available through the machines? (“X” all that apply)

Candy, chips, or cookies ____________

Soda ____________

Pretzels ____________

Fresh vegetables ____________

Salads ____________

100% fruit juice ____________

Fresh fruit ____________

Dried fruit ____________

Granola bars or trail mix ____________

Yogurt ____________

1% or skim milk ____________

Water ____________

12.  Can your employees obtain any of the following foods in the work place?
(“X” all that apply)

Fresh fruit ____________

100% fruit juice ____________

Cooked vegetables ____________

Fresh salads ____________

Fat free or low fat salad dressing ____________

1% or skim milk ____________

Fat free or low fat yogurt ____________

13.  Does your organization have written policies or guidelines to ensure that fruit, vegetables and salad are offered at catered meetings?

14.  Does your organization have a place where employees can refrigerate and heat meals?

15.  Does your organization offer nutrition education programs to your employees?

16.  Does your organization offer weight control programs?

17.  Does your organization offer reimbursement or discounts for dietary counseling, whether through health insurance or direct subsidy?

Smoking

18.  Does your organization have a written smoke-free environment policy?

If No, go to 22.

19.  Are employees who violate the policy penalized in any way?

20.  Where is smoking prohibited (“X” all that apply)

In offices ____________

Throughout the office building ____________

Throughout the grounds ____________

In company vehicles ____________

21.  Where is smoking permitted?  (“X” all the apply)

In offices ____________

In designated areas of buildings ____________

Outside of office buildings ____________

In company vehicles ____________

22.  Do you offer programs to help employees quit smoking?

23.  Does your organization offer reimbursement or discounts to employees who enroll in programs to quit smoking, whether through health insurance or direct subsidy?

Other Health Programs

24.  In the past 12 months, has your organization offered employees any health education classes, workshops, lectures or special events?

25.  In the past 12 months, has your company offered any of the following health screening services?  (“X” all that apply)

Blood pressure screening ____________

Cholesterol screening ____________

Blood sugar screening ____________

Other: (describe):______________

26.  Are your employees allowed to use paid work time to participate in health-related activities?

a. If Yes, is this for: 

Activities at work? ____________

Time off to participate elsewhere? ____________

b. If Yes, in which activities are employees allowed to use paid work time for participation?  (“X” all that apply)

Blood pressure screening ____________

Cholesterol screening ____________

Blood sugar screening ____________

Nutrition classes ____________

Physical activity ____________

Classes to quit smoking ____________

Weight control programs ____________

Stress management ____________

27.  Does your organization have a written flextime policy?

28.  Does your organization participate in an Employee Assistance Program?

29.  In the past 12 months, has your organization solicited feedback from employees on the types of health programs and services that would be beneficial to them?

30.  Does your organization have a budget for colleague health promotions?

31.  Is there a designated person, group or committee within your organization who Is responsible for employee health promotion?

32.  Does your organization offer family leave for employees to care for sick family members?

About Your Organization

33.  How would you describe the attitude of your organization’s leadership toward the promotion of health among your colleagues?

Strongly supportive ____________

Somewhat supportive ____________

Neutral attitude ____________

Not very supportive ____________

Not at all supportive ____________

34.  Which of the following statements best describes your organization’s health insurance benefit?

a.  We do not offer health insurance to employees ____________

b.  We offer a health insurance plan, but do not contribute a % of the premium ____________

c.  We offer a health insurance plan, and contribute a % of the premium ____________

35.  How many employees work in your business? include full and part time employees)

Fewer than 50 ____________

50 to 249 ____________

250 or more ____________

36.  What % of your employees are women?  Percent: 

37.  What % of your employees are disabled?  Percent: 

38.  What % of your employees are: 

Percent:  Full-time
Percent:  Part-time
Percent:  Satellite/offsite employees

39.  Does your organization work more than one shift per day? If Yes, do employees on all shifts have equal access to the following resources? (“X” all that apply)

Physical activity programs ____________

Fresh fruits, vegetables, low fat foods ____________

Health screenings ____________

Nutrition education programs ____________

Weight loss programs ____________

Tobacco cessation programs ____________