Membership Form

Information to be reflected in our 2008 Wellness Guide
General Information
Name of worksite/school/group:
 

County located in:
 

Approximately how many employees are there at your worksite?

Does your worksite currently make efforts of promoting wellness to employees?

Does your worksite provide health insurance to you?

Does your worksite currently do training and/or education on:

a) Heart Disease b) Stroke c) High Blood Pressure d) Cholesterol

If you answered No to any of the above, does your worksite make any efforts regarding these topics?


If yes, please explain.


How would you most like to learn about these topics? Check all that apply:

Does your worksite have any written policy or policies recommending the use of healthier foods for holiday celebrations or staff meetings?


If yes, are employees told about the healthy foods policy or policies during orientation?


Does your worksite have a refrigerator designated for food or employee use?


Does your worksite have any equipment and sink access available for employees to use to prepare and eat meals?


Does your worksite have vending machines?


If yes, do the vending machine(s) offer at least 5 healthy choices? Healthy choices include: fresh fruits, whole grain chips, or baked chips, products with the ‘smart choices made easy’ logo, etc.


Does your worksite have a cafeteria?


If yes, does your cafeteria offer at least 5 healthy choices like 100% juice products, fresh fruits or whole grain products?


Has information on healthy food choices been provided to employees in the past year?
How provided?


Does your worksite have any written policy or policies encouraging physical activity during the workday?


Does your worksite have stairs?


If yes, are the stairs safe, clean and well-lit?


Does your worksite have a safe place for walking or other activities on-site or near-by?
Name of near-by facility:


Does your worksite sponsor any physical activities, teams or clubs?
Name of activity:


Does your worksite sponsor any community-based activities, teams or clubs?
Name of activity:


Has information on physical activity been provided to employees in the past year?
How provided?


Does your worksite have any written policy or policies supporting and encouraging communication that is open, two-way and respectful of employee diversity?


Does your worksite have any place for employees to reduce the physical and mental stress of the workday? (Like a quite room)


Has any activity or activities been provided for dealing with significant changes in the worksite in the past 2 years? A significant change may be a change in management, high staff turnover or loss, or changes in work conditions?
What was done?


Has any program(s) or material(s) for managing stress been provided at your worksite in the past year? This might be a class for supervisors, relaxation, communication or time management.
What was provided?


Does your worksite have any written policy or policies that prohibits or restrict smoking at the worksite?


If yes, is smoking permitted outside on workplace grounds?


If yes, is smoking permitted anywhere in the worksite buildings?


If yes, are signs posted for smoking or non-smoking areas?


Has any information on health effects of tobacco been provided to employees in the past year?
How provided?


Have smoking or tobacco cessation programs been offered on-site during the last year?
What?
Employee Interest
Please indicate how likely you would be to participate in each of the following programs if they were offered at work during the next year.

Body fat testing:
Education programs on:

Back Safety Cancer Prevention Heart Disease Prevention Stroke Prevention Programs Cholesterol Reduction Home Safety Substance Abuse Headache Prevention and Treatment Cold/Flu Prevention and Treatment

Employee Assistance Programs On:

Depression Treatment Financial Managment Job Stress Managment Accepting Change Parenting Difficulties Managing Chronic Health Conditions (diabetes, hypertension) Managing Chronic Pain (neck and shoulder injuries, back injuries, etc.) Controlling Anger/Emotions

Fitness Programs On:

Corporate Fitness Membership Rates Exercise Tolerance (STRESS) Testing On-site, Low-impact Exercise Equipment Prescribed Exercise Programs Stretching Programs Walk-Fit Programs

Immunization Programs:

Flu Shots Tetanus Shots Lyme Disease Vaccine Hepatitis 'B' Vaccine

Nutrition Education Programs:

Healthy Cooking (meals/snacks) Healthy Eating (do's/don'ts) Weight Managment Programs (diet and exercise) Onsite Vending Machines with healthy choices

Screening Programs:

Blood Pressure Checks Blood Suger (diabetes) Cholesterol levels Multiphasic Blood Screenings (test cholesterol, blood sugar, etc.) Cardiovascular (EKG’s) Colon/Rectal (cancer) Prostate Checks (PSA) Stool checks (bowels) Mammograms Vision Other…specify

Smoking Cessation Programs

Stress Reduction Programs

Time Managment Programs

Visiting on-site health nurse

Self help/self-care

Please indicate how likely you would be to participate in health promotion programs during the following times:

Health Promotion Programs:
Before Work During Lunch at Work After Work

ANY OTHER INTEREST OR SUGGESTIONS (PLEASE SPECIFY). Please list any positive (or negative) comments regarding the impact of the current wellness program. Include how this program may have affected you personally. List any suggestions on how we can improve the current program or things you would like to see implement. Your input is an IMPORTANT element to the success of our program.
Wellness Questions
Please indicate how likely you would be to participate in each of the following programs if they were offered at work during the next year.

Current physical activity level.
Please read the statements below. Select the statement that best describes your current level of physical activity. When considering time spent being active, count any time you are active for at least 10 minutes at a time. In other words, if you have three 10 minute “bouts” of activity in a day, record that as 30 minutes in a day. “Vigorous” exercise includes activities like jogging, running, fast cycling, aerobics classes, swimming laps, singles tennis and racquetball. These types of activities make you sweat and make you feel out of breath. “Moderate” exercise includes activities such as brisk walking, gardening, slow cycling, dancing, doubles tennis or hard work around the house.





When do you get most of your physical activity each day?
Fruits and Vegetables.
Please read the statements below. Select the statement that best describes your current intake of 100 % juices and fresh, frozen or dried fruits and vegetables. A serving is ½ cup or 1 medium piece of most fresh or frozen fruits and vegetables, 6 ounces of 100% juice and ¼ cup of dried fruits and vegetables.




Fat in Foods.
Whole Grains.
Please read the statements below. Select the statement that best describes your current intake of whole grain foods. The serving size for whole grains is one ounce (ex. 1 slice of bread, 1 oz. of cereal, ½ cup of cooked rice or pasta).





Tobacco Use.
Anxiety
About how often during the past 30 days did you feel nervous or anxious: would you say all of the time, most of the time, some of the time, a little of the time or none of the time?





Depression
About how often during the past 30 days did you feel sad, blue or depressed- would you say all of the time, most of the time, some of the time, a little of the time, or none of the time?





Participant Interest Areas
Please rate your interest in any of the following individual physical activity resources for that might be available.

a)Attending regular presentations on physical activity topics





 b)Receiving regular physical activity tips via e-mail





 c)Having access to web resources on physical activity





 d)Getting information on existing activities in the area





 e)Point of decision prompts to help you be active (stair/elevator signs)
What physical activity topics are you interested in learning more about?

a)Joining small groups for regular activity (walking groups, yoga class)





 b)Forming clubs for particular physical activities





 c)Discounted memberships at local health clubs, recreation centers, etc.





 d)Participating in a division-wide fitness program initiative with friendly competition between groups.
Please rate your interest in any of the following nutrition resources that might be available?

a)Attending regular presentations on nutrition topics





 b)Receiving regular healthy eating tips via e-mail





 c)Having access to web resources on nutrition/healthy eating





 d)Getting information on existing food/diet groups in the area





 e)Recipes healthy meal ideas





 f)Point of decision prompts to help you eat well (i.e. strategically placed healthy eating reminders)





 g)Joining small groups for regular information on diet (ex. Weight watchers)
What nutrition topics are you interested in learning more about? Please rate your support for any of the following policy or environmental worksite changes.

a)Review healthy food options for the cafeteria and vending machines; healthy food options labeled.





b)Develop an organization recommendation on food choices for meetings and conferences.





 c)Not schedule meetings within the organization on a specific day/time to allow for open time for wellness activities





 d)Provide preventive wellness screenings, (blood pressure, body composition, blood cholesterol, diabetes)





 e)Provide health risk appraisals





 f)Provide incentives for participation





 g)Develop policies to support breastfeeding women
Please rate your interest in any of the following mental health resources that might be available?

a)Attending regular presentations on mental health topics





 b)Receiving regular mental health tips via e-mail





 c)Having access to web resources on mental health





 d)Getting information on existing mental health groups in the area





 e)Joining small groups for regular stress reduction classes (relaxation or yoga classes)
If more opportunities were available for wellness at the worksite, when would be the best time for you? Check all that apply:
What other things could be done in the worksite to help promote wellness? What would you like to see?



Please rate your interest in any of the following mental health resources that might be available?

a) Gender
b) Age
b) Work Unit
Other...Please write in: