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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 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 Male      Female Female

    Male Non-Binary       Female Prefer not to say

2. Age Group:

    under 21 under 21    21 - 30  21 - 30     31 - 40 31 - 40     

    41 - 50 41 - 50      51 - 60 51 - 60      over 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 help Yes       No help needed No     Not sure 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 Monday Spring Spring Before work Before work
Tuesday Tuesday Summer Summer Lunch time Lunch time
Wednesday Wednesday Fall Fall After work After work
Thursday Thursday Winter Winter Evenings Evenings
Friday Friday    
Weekends Weekends (for family events)

Are there other factors that affect participation? Please indicate

                                                                                                                                                           
 
 
 

8. Where would you prefer to attend activities?

    Work In the workplace
    Private Health Club At a private health club
    Local School or Facility/Hall At a local School or facility/hall
    Other Other, please specify:__________________

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

    Yes share costs Yes    No don't share costs No

No don't share costs Up to a certain amount (please specify _______________)

10. Do you have any additional comments or concerns?

                                                                                                                                                          
 
 
 

Document last updated on September 29, 2022
Document confirmed current on May 3, 2017

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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.