« Go Back Sample Organizational Health Survey

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 ____________