Workplace Health and Well-being - Sample Workplace Health and Well-being Survey

Workplaces often use a survey to determine interest in the various aspects of a workplace health and well-being program. The following is a sample. You can customize this survey according to the needs of your workplace. See the OSH Answers on Workplace Health and Well-being Program - Getting Started for more information.

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 initiatives 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 survey because we would like to keep this survey confidential.
• Please complete and submit the survey by [date/month/year]

1. Gender:

     Male      Female

     Non-Binary       Prefer not to say

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? If so, briefly describe your concerns.

4. Would you like [ABC Company] to help with these concerns?

     Yes       No      Not sure

Please explain your answer

5. Indicate how you feel about the following statements:

	Agree Strongly	Agree	Neutral	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 my work-life balance.
The level of control I have over my work matches the level of responsibly I am assigned.

 

6. Would you participate in the following activities if offered?

	Yes	No	Maybe
Aerobic exercise sessions
Walking club
Recreational team (e.g., baseball)
Other exercise programs. Please specify:___________________________
Tips for healthy backs
Tips for healthy eating (general tips, etc.)
Tips for weight management
Flu shot or other vaccines clinic
Blood pressure screening
Blood glucose screening
Tips for stress management
Substance use and abuse education
Smoking cessation program
Parenting tips
Interpersonal skills workshop (such as "Dealing with Difficult People", Conflict Resolution, etc.)
Retirement planning workshop
Lunch & learn sessions
Time management skills workshop
Personal finance workshop
Tips for work/life balance
Other: (please specify)

7. When are you most able to participate in activities?

Day of the Week	Season	Time Period
Monday	Spring	Before work
Tuesday	Summer	Lunch time
Wednesday	Fall	After work
Thursday	Winter	Evenings
Friday
Weekends (for family events)

Are there other factors that affect participation? Please indicate

8. Where would you prefer to attend activities?

     In the workplace
     At a private health club
     At a local School or facility/hall
     Other, please specify:__________________

9. If necessary, would you be willing to share in the cost of a program?

     Yes    No

Up to a certain amount (please specify _______________)

10. Do you have any additional comments or concerns?