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?
Health Management Initiative Assessment
(For health managers, employee managers, human resources dept., or employee health nurses)

Check the line that applies closest to your organization.

Our senior management is committee to health promotion as an important involvement in our human capital.


Our health and productivity strategies are aligned with our business goals.


All levels of management are educated regarding the link between employee health and productivity and total economic value.


Our employees are educated about the real costs and total value of personal health and its impact on business success.


We have identified the leading physical and mental health condition among our employees and know their related direct and indirect costs.


We try to capture and link key medical costs with indirect costs such as diability, sick days, and worker’s compensation claims.


Our health benefits support prevention, risk reduction and disease management, and are free of barriers to evidence-based interventions.


Our incentives support employee responsibility and motivate employees to stay healthy, reduce high-risk behaviors, improve clinical measures, and/or adhere to disease management regimens.


To encourage employee fitness, we subsidize gym memberships an/or provide onsite fitness facilities, walking trails, and well-lit accessible stair wellness.


We provide healthful food selections in our vending machines/cafeteria.


We provide a safe and clean work environment.


An employee leadership network supports our health management programs.


We offer health risk assessments (HRAs) to all employees at least every three years with appropriate follow-up and referral.


We provide a variety of initiatives that support primary prevention (e.g. preventive health screenings, flu immunizations) and lifestyle management (e.g., physical activity, nutrition, stress management).


We provide education about medical consumerism and self-care.


We provide health risk reduction programs or resources (e.g., weight management, smoking cessation).


We provide disease management programs and/or resources targeted to conditions with high-cost productivity implications (e.g., asthmas, diabetes).


We measure program effectiveness by stated health/productivity goals. (For ex., 70 percent of our workforce is categorized as low risk).


Eighty percent of our workforce has participated in at least two company-sponsored health promotion programs within the past three years, including a health risk assessment (HRA) and a health improvement or risk reduction program.