1. Who is the
single most active person (coordinator
or organizer) for your wellness
program?
a) me
b) an employee
I appointed
c) an employee
who volunteered
d) other (specify
below)
specify
"other" or make
additional comments
2. Why is the
person identified in question #1
active in your worksite wellness
program?
a) job description
or supervisor/manager appointment
b) a personal
interest in organizing employee-centered
programs or events
c) a personal
interest in health, fitness or nutrition
d) other (specify
below)
specify
"other" or make
additional comments
3. Is there a
committee at your worksite that
--- according to it's mission or
goals --- addresses and directs
wellness issues and programs for
employees at your worksite?
a) yes
b) one is planned,
but we have not yet begun the process
c) we are in the
process of forming a committee
d) steps were
taken to form one, but not enough
members could be recruited
e) there are no
plans to form a wellness committee
In
questions 4-6 the term "wellness
committee" refers to the entity
described in question 3. If a question
is not applicable to your situation,
please select "NA".
4. How many members
do you have now or plan to
have on your wellness committee?
a) 2-3
b) 4-6
c) 7-12
d) >12
e) NA
5. Does your
wellness committee have a regular
meeting schedule? NOTE: if you have
a committee that has not yet met,
answer this question based on your
anticipated schedule, then check
"haven't met this year" in next
question.
a) yes, and most
meetings are held
b) yes, but meetings
are often canceled
c) no, we meet
when necessary or someone calls
a meeting
d) haven't set
a meeting policy
e) don't know
f) NA
6. How often
has your wellness committee met
this year?
a) 1x
b) 2-4x
c) 5-9x
d) 10+x
e) haven't met
this year
f) NA
7. How much have
you used the Healthy Heart Worksite
Project (HHW) web site ?
a) Frequently,
at least once a week
b) Some, at least
once a month
c) Very little,
a few times this year
d) didn't know
there was a web site
e) None
8. What is your
sense of employees' acceptance of
a wellness program?
a) positive overall;
support employer involvement
b) positive overall;
neutral about employer involvement
c) general acceptance
d) negative; consider
it employer intrusion
e) mixed; strong
feelings on both sides
f) don't know
9. How have you
publicized your wellness program
to your employees? (Check all
that apply; hold down the Control
key to make multiple selections.)
a) paycheck stuffers
b) posted info
on a bulletin board
c) email
d) intranet
f) other flyer
(posted on wall or available in
common area)
g) have not publicized
h) other (specify
below)
specify
"other" or make
additional comments
10. How much
is upper management involved in
your wellness program or activities?
a) lots
b) some
c) little
d) none
e) don't know
11. How many
employees overall (including yourself,
wellness committee, and upper management)
have been involved in any aspect
of your wellness program?
a) one
b) 2-3
c) 4-6
d) 7-12
e) >12
12. How much
should the Tompkins County Health
Department (TCHD) be involved in
your wellness program?
a) much more than
it has been so far
b) somewhat more
than it has been so far
c) about right
d) somewhat less
than it has been so far
e) much less than
it has been so far
13. In what
ways should the Tompkins County
Health Department (TCHD) be involved
in your wellness program? (Check
all that apply; hold down the Control
key to make multiple selections.)
a) financing
b) available by
phone or email when we have a question
c) attend our
wellness committee meetings
d) schedule our
wellness committee meetings
e) facilitate
communication between HHW participating
worksites
f) provide programs
g) run programs
h) provide newsletter
i) provide web
site
j) buy incentives
k) not at all
l) other (specify
below)
specify
"other" or make
additional comments
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For
Questions 14 thru 21, select one
best answer based on your agreement
with the given statement.
14. I'm glad
my worksite was chosen for this
program
a) Strongly agree
b) Somewhat agree
c) Somewhat disagree
d) Strongly disagree
15. A wellness
program is more work than I expected
a) Strongly agree
b) Somewhat agree
c) Somewhat disagree
d) Strongly disagree
16. I feel positive
about the progress of our program
this year
a) Strongly agree
b) Somewhat agree
c) Somewhat disagree
d) Strongly disagree
17. We can no
longer continue the program
a) Strongly agree
b) Somewhat agree
c) Somewhat disagree
d) Strongly disagree
18. I think all
worksites should have some kind
of wellness program
a) Strongly agree
b) Somewhat agree
c) Somewhat disagree
d) Strongly disagree
19. Our worksite
is too small to have a wellness
program
a) Strongly agree
b) Somewhat agree
c) Somewhat disagree
d) Strongly disagree
20. Based on
my experience so far, I would not
agree to participate in this program
if asked
a) Strongly agree
b) Somewhat agree
c) Somewhat disagree
d) Strongly disagree
21. The wellness
objectives we adopted for the HHW
program are not suited to this worksite
a) Strongly agree
b) Somewhat agree
c) Somewhat disagree
d) Strongly disagree
e) Don't know
Top
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22. How might
each of the following factors, as
they may exist at your worksite ,
influence the degree to which your
worksite wellness program can succeed?
(Factors
are listed A thru R.)
For
example , for question 22-A you
will be completing the following
phrase:
"A
diverse workforce might influence
the outcome of our wellness program...
A
Lot
"The
following factor, as it exists
at our worksite...
"might
influence the outcome of our
wellness program...
A. a diverse
workforce
1) A Lot
2) Some
3) None
4) NA
B. a homogeneous
workforce
1) A Lot
2) Some
3) None
4) NA
C. regular
work schedules
1) A Lot
2) Some
3) None
4) NA
D. irregular
work schedules
1) A Lot
2) Some
3) None
4) NA
E. strong
interest from top management
1) A Lot
2) Some
3) None
4) NA
F. little
interest from top management
1) A Lot
2) Some
3) None
4) NA
G. effective
communication channels within
our organization
1) A Lot
2) Some
3) None
4) NA
H. inadequate
communication channels within
our organization
1) A Lot
2) Some
3) None
4) NA
I. a culture
that encourages broad social
interaction (e.g., company-wide)
1) A Lot
2) Some
3) None
4) NA
J. a culture
that offers few opportunities
for social interaction
1) A Lot
2) Some
3) None
4) NA
K. a product
that depends on having departments
or functional units work closely
with each other
1) A Lot
2) Some
3) None
4) NA
L. a product
with little or no dependence
on departments coordinating
work flow or activities
1) A Lot
2) Some
3) None
4) NA
M. a parent
company headquartered outside
of Tompkins County
1) A Lot
2) Some
3) None
4) NA
N. a changing
business climate
1) A Lot
2) Some
3) None
4) NA
O. a changing
organizational structure
1) A Lot
2) Some
3) None
4) NA
P. a strong
organizational structure
1) A Lot
2) Some
3) None
4) NA
Q. flexible
work flow or job descriptions
1) A Lot
2) Some
3) None
4) NA
R. inflexible
work flow or job descriptions
1) A Lot
2) Some
3) None
4) NA
23. Additional
Comments are welcome
Top
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1 | 14 | 22 | Top
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