Workplaces often use a survey form to determine interest in the various aspects of a workplace health and wellness program. The following is a sample. Be sure to customize it for your needs at your workplace. See the OSH Answers on Workplace Health and Wellness Program - Getting Started for more information on programs in general.
ABC Company is looking into the need for a workplace health and wellness program. We are interested in learning more about your opinions and interests. Your answers will be used to help plan the program and to decide which types of programs to offer.
2. Age Group:
under 21 21 - 30 31 - 40
41 - 50 51 - 60 over 60
3. Do you have any health concerns about yourself, your family, or something arising from the workplace?
4. Would you like ABC Company to help with these concerns?
Yes No Not sure
Explain your answer
5. Indicate how you feel about the following statements:
|Agree Strongly||Agree||Not sure/ |
|On the whole, I like my job.|
|I feel that I am well rewarded for the effort I put in at work.|
|I am happy with the balance between my work time and my leisure time.|
|At work, my level of authority is about the same as my level of responsibility.|
6. Which of the following activities would you prefer to participate in? (Check all that you would be likely to join)
|Recreational Team (e.g. baseball)|
|Other exercise programs (specify)|
|Healthy Eating (general tips, etc.)|
|Blood Cholesterol Testing|
|Blood Pressure Screening|
|Blood Glucose Screening|
|Body/Mass Index (BMI) Testing|
|Stress Management (either home/work)|
|Alcohol / Drug Abuse Education|
|Interpersonal Skills (such as "Dealing with Difficult People", Conflict Resolution, etc.)|
|Lunch & Learn Sessions|
|Home Budgeting / Financial Planning|
|Health Fair (booths)|
|Balancing Family and Work|
|Other: (please list)|
7. When would you be able to participate?
|Day of the Week||Season||Time Period|
|Weekends (for family events)|
8. Where would you prefer to attend a program?
Private Health Club
Local School or Facility/Hall
9. If necessary, would you be willing to share in the cost of a program?
10. Do you have any additional comments or concerns you would like the committee to know?
Document last updated on February 2, 2009