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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 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 Male      Female Female

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?

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

    Yes help Yes       No help needed No     Not sure 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 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 Other Other  
Weekends Weekends (for family events)

8. Where would you prefer to attend a program?

    Work Work
    Private Health Club Private Health Club
    Local School or Facility/Hall Local School or Facility/Hall
    Other Other

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

10. Do you have any additional comments or concerns you would like the committee to know?

                                                                                                                                                          
 
 
 

Document last updated on February 2, 2009
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.