Employee Interest Survey

Following is a "generic" employee interest survey that we have used with success as a template for our worksites. Include a brief intro such as the following:

The Wellness Committee is working to develop a worksite wellness program for our company. We want to know what you want to see in a program that supports healthier lifestyle choices and provides more opportunities for physical activity and better eating habits.

This survey will take 5 or fewer minutes. SELECT ONE best answer for each statement or question, unless otherwise indicated. Please comment freely in the spaces provided at the end.

Thank you for sharing your thoughts on building a healthier workplace.

	Select ONE best answer for each statement or question	YES	MAYBE	NO
1	I would join a gym or fitness center if a discount or reimbursement were available.
2	I would participate in recreation opportunities onsite as a way to get more physical activity during the week. If Yes or Maybe, check which of the following look good: ___ a Wii™ or other video game console with physical activity games ___ a treadmill or other fitness equipment inside ___ a regular walking group ___ a map showing good walking routes ___ scheduled exercise programs like a class onsite Other ___________________________________
3	I would be more likely to join in recreation activities or do some personal exercise during my down time if a shower and changing area were available.
4	I am interested in learning new exercises that could help prevent or ease some of the physical pains we get from sitting, like back pain or stiff shoulders.
5	Time is a main reason why I can’t get enough exercise or activity. There is just not enough time to fit it in.
6	A program with goals for me and my co-workers is a good way to try out new ideas for a healthier living.
7	I would like to find ways to eat healthier foods at meals and for snacks.
8	If we had more choices in the snack bar, I would buy the healthier snacks.
9	I would buy local fruits and vegetables to take home if my order was delivered to work.
10	I would join a program that helps me develop healthier eating habits in order to lose weight or feel more fit.
11	I would participate in free, *confidential* screenings for medical conditions if offered at work (e.g., blood pressure, diabetes, cholesterol, height-weight, smoking).
12	I would like to learn more about how our health plan benefits can help with lifestyle changes or disease prevention (e.g., for diabetes or heart disease).
13	Would you take a Health Risk Assessment? A Health Risk Assessment is a *confidential* survey that asks questions about your health and life style habits and identifies your risk of developing medical conditions (such as diabetes, stroke, heart disease).
14	Would you be interested in personal help with managing your health risks if it were available by phone or online?
15	Would you be more likely to take steps to improve your health if you were rewarded for doing so?
	Select ONE best answer for each statement or question	Yes	Some- times	No
16	I smoke.
17	I maintain a healthy weight.
18	Overall, I feel that I live a healthy lifestyle.
19	Overall, my family/ household members live or support my efforts to live a healthy lifestyle.
20	My job responsibilities can be a barrier to living a healthy lifestyle.
21	My family responsibilities can be a barrier to living a healthy lifestyle.
22	My old habits can be a barrier to living a healthy lifestyle.