Workplace Health and Well-being - Sample Workplace Health and Well-being Survey
What is an example of a workplace health and well-being survey?
Workplaces often use a survey form to determine interest in the various aspects of a workplace health and well-being 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 Well-being Program - Getting Started for more information on programs in general.
Sample Workplace Health and Well-being Survey
ABC Company is looking into the need for a workplace health and well-being 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.
- Senior management has agreed to let everyone take a few minutes to complete this survey.
- Please do not put your name on the form because we would like to keep this survey confidential.
- Please return the forms by putting them in a sealed envelope and placing them in the inter-office mail.
1. Sex:
Male Female
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/ No opinion | Disagree | Disagree Strongly | |
|---|---|---|---|---|---|
| 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)
| Yes | No | Maybe | |
|---|---|---|---|
| Aerobic exercise | |||
| Walking Club | |||
| Recreational Team (e.g., baseball) | |||
| Other exercise programs (specify) | |||
| Healthy Backs | |||
| Healthy Eating (general tips, etc.) | |||
| Weight Management | |||
| Blood Cholesterol Testing | |||
| Flu Shots | |||
| Blood Pressure Screening | |||
| Blood Glucose Screening | |||
| Body/Mass Index (BMI) Testing | |||
| Stress Management (either home/work) | |||
| Alcohol / Drug Abuse Education | |||
| Smoking Cessation | |||
| Parenting | |||
| Marital Situations | |||
| Interpersonal Skills (such as "Dealing with Difficult People", Conflict Resolution, etc.) | |||
| Retirement Planning | |||
| Lunch & Learn Sessions | |||
| Time Management | |||
| 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 |
|---|---|---|
| Monday | Spring | Before work |
| Tuesday | Summer | Lunch time |
| Wednesday | Fall | After work |
| Thursday | Winter | Evenings |
| Friday | Other | |
| Weekends (for family events) | ||
8. Where would you prefer to attend a program?
Work
Private Health Club
Local School or Facility/Hall
Other
9. If necessary, would you be willing to share in the cost of a program?
Yes No
10. Do you have any additional comments or concerns you would like the committee to know?
Document confirmed current on May 3, 2017
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Disclaimer
Although every effort is made to ensure the accuracy, currency and completeness of the information, CCOHS does not guarantee, warrant, represent or undertake that the information provided is correct, accurate or current. CCOHS is not liable for any loss, claim, or demand arising directly or indirectly from any use or reliance upon the information.