Summary of Heart Check Survey Questions

Preliminary Info  |  Demographics  |  Smoking  |   Nutrition  |  Physical Activity   |   Stress  |   Screening  |   Administrative  |  Organization

1 PRELIMINARY INFORMATION

1.1 Name of organization.

1.2 Name of rater.

1.3 Date of interview.

1.4 Name of interviewee.

1.4.1 Current title or position of interviewee.

1 CEO/President/Administrator/Comptroller

2 Director/Administrator (except personnel)

3 Assistant to the Director/ Administrator/ Commissioner/ Vice President (except personnel)

4 Personnel Manager or Director/Human Resource Manager/Other Personnel position

5 Benefits Manager

6 Health and Safety Officer

7 Health Promotion/Wellness Manager

8 Dietary/Nutritional/Food Service Manager/Chef/Other Food Services

9 Occupational Nurse

10 Company Physician

11 Other Manager/Officer

12 Labor Representative/Union Steward, Etc.

13 Clerical/Administrative Assistant

14 Teacher

15 Other

2 ORGANIZATIONAL DEMOGRAPHICS

2.1 Is the worksite self-insured for employee health and medical benefits?

2.2 In which industrial sector is this worksite located?

2.3 About what percent of the workforce is unionized?

2.4 As of the last payroll and not counting temporary or seasonal employees, how many employees:

2.4.1 work here?

2.4.2 work full time?

2.4.3 work part time?

2.4.4 are female?

2.4.5 are racially white?

2.4.6 are under 40?

2.5 What is the average wage of employees:

2.5.1 average weekly wage OR

2.5.2 average annual salary

2.6 Excluding any security staff, which of the following work shifts does this worksite have?

2.7 Approximately what percent of full and part-time employees at this worksite would be classified as manual labor?

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3 SMOKING

3.1 Does the worksite have a written smoke free work environment policy?

3.1.1 What is the extent of the smoking ban?

1 a partial ban on smoking (designated or de facto smoking areas in the building)

2 smoking allowed on the grounds but not in the building

3 a total ban throughout the premises (including grounds)

3.2 Does the worksite provide any type of incentives for being a non-smoker or quitting smoking

3.3 Did this worksite provide directly or promote insurance company sponsored smoking cessation programs/services during the previous 24 months?

3.3.1 provides or promotes on-site programs

3.3.2 provides or promotes off-site programs

3.3.3 subsidizes at least half by the company

3.3.4 uses credentialed instructors (someone officially qualified)*

3.3.5 uses more than one form of program delivery (e.g., self-study materials such as computers, video/audio cassettes, self-paced learning manuals)

3.3.6 promotes the availability of programs through at least two communication channels (newsletters, bulletin boards)

3.3.7 provides access during company time (not lunch hour)

3.3.8 has a written plan to identify and recruit high risk individuals.

3.3.9 provides or subsidizes the use of the nicotine patch or other nicotine substitute products in conjunction with the program.

3.3.10 provides incentives to increase participation

3.3.11 evaluates by asking participants their perceptions of program quality (e.g., program-end surveys)

3.3.12 evaluates the program by comparing pre-determined objectives to outcome measures (e.g., % of smokers who quit)

3.4 Does the worksite provide for the sale of tobacco products on site (e.g., vending machines, vendors)?

3.5 Did the worksite provide anti-smoking educational messages to the general employee population during the previous 12 months such as through posters, brochures, videos or lectures?

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4 NUTRITION

4.1 Does the worksite have vending machines for employees to access food during working hours?**

4.2 Does the company have a cafeteria?**

4.3 Did the worksite provide directly or promote insurance company-sponsored weight control programs during the previous 24 months?

Yes / No

4.3.1 provides on-site programs

4.3.2 provides off-site programs

4.3.3 subsidizes at least half by the company

4.3.4 uses credentialed instructors*

4.3.5 uses more than one form of program delivery (e.g., self-study materials such as computers, video/ audio cassettes, self-paced learning manuals)

4.3.6 promotes the availability of programs through at least two communication channels (newsletters, bulletin boards)

4.3.7 provides access during company time (not lunch hour)

4.3.8 has a written plan to identify and recruit high risk individuals

4.3.9 provides incentives to increase participation

4.3.10 evaluates by asking participants their perceptions of program quality (e.g., program-end surveys)

4.3.11 evaluates the program by comparing pre-determined objectives to outcome measures (e.g., % of pounds lost)

4.4 Did the worksite provide directly or promote insurance company sponsored "healthy eating" programs during the previous 24 months?

Yes / No

4.4.1 provides on-site programs

4.4.2 provides off-site programs

4.4.3 subsidizes at least half by the company

4.4.4 uses credentialed instructors*

4.4.5 uses more than one form of program delivery (e.g., self-study materials such as computers, video/ audio cassettes, self-paced learning manuals)

4.4.6 promotes the availability of programs through at least two communication channels (newsletters, bulletin boards)

4.4.7 provides access during company time (not lunch hour)

4.4.8 has a written plan to identify and recruit high risk individuals

4.4.9 provides incentives to increase participation

4.4.10 evaluates by asking participants their perceptions of program quality (e.g., program-end surveys)

4.4.11 evaluates the program by comparing pre-determined objectives to outcome measures (e.g., de-creased fat consumption)

4.5 Does the worksite subsidize or provide free food options for employee meetings?

Yes / No

4.5.1 Subsidize or provide nutritious (See Guidelines for Heart Healthful Food at the Worksite) food options (free apples, juices, popcorn, etc.) for employees, including at meetings?

4.5.2 Subsidize or provide non-nutritious food options (free coffee, soda, donuts, etc.) for employees, including at meetings?

4.6 Did the worksite provide healthy eating messages to the general employee population during the previous 12 months such as through posters, newsletters, bulletin boards, brochures, videos or lectures, etc.

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5 PHYSICAL ACTIVITY

5.1 Does the Worksite provide a shower and changing facility for employees who want to bike/run/walk to work or exercise during off hours (lunch)?**

5.2 Does the worksite provide an exercise facility on site? **

5.3 Does the worksite subsidize exercise facility memberships off site?

5.4 Has the worksite provided or promoted insurance company sponsored fitness oriented programs for employees other than use of an exercise facility during the previous 24 months? (e.g., walking, stretching, low back health exercises, aerobics)

5.5 Does the worksite sponsor sports teams or events (e.g., corporate challenge) for employees?

5.6 Has the worksite provided or subsidized fitness assessments during the previous 24 months?

5.7 Does the worksite provide or maintain outdoor exercise areas or playing fields for employee use?

5.8 Does the worksite have a written policy statement supporting employee physical fitness

5.9 Does the worksite provide any type of incentives for engaging in physical activity?

5.10 Has the worksite provided exercise/physical fitness specific messages to the general employee population during the previous 12 months such as through posters, brochures, videos or lectures etc.?

5.11 Does the worksite organize or sponsor a lunch time/after work walking club?

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6 STRESS

6.1 Does the worksite provide an employee assistance program (EAP)?

6.2 Did the worksite sponsor or organize regular social events (company picnic, Holiday party, etc.) during the previous 12 months?

6.3 Did the worksite provide directly or promote insurance company sponsored educational programs for stress or related issues (e.g., relaxation training, assertiveness, communication, time management, social interactions) during the previous 24 months?

6.4 Did the worksite provide management training on workplace stress related issues (performance review, communication, personnel management, etc.) during the previous 24 months?

6.5 Does the worksite provide an employee lounge (non-cafeteria and for employees only) where employees can take a break?

6.6 Does the worksite provide a facility where employees can go to practice relaxation exercises** (e.g., mediation, yoga, biofeedback)?

6.7 Does the worksite have a sexual harassment policy?

6.8 Did the worksite provide stress management educational messages to the general employee population during the previous 12 months such as through posters, brochures, videos or lectures, etc?

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7 SCREENING

7.1 Did the worksite provide blood pressure screening (beyond pre-employment physicals) during the previous 24 months?

7.2 Did the worksite provide cholesterol screening during the previous 24 months?

7.3 Did the worksite provide blood tests for sugar during the previous 24 months?

7.4 Did the worksite provide health risk appraisal assessments during the previous 24 months?

7.5 Does the worksite make blood pressure monitoring devices available for employee self assessments?

7.6 Did the worksite provide health screening educational messages to the general employee population during the previous 12 months such as through posters, brochures, videos or lectures, etc.?

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8 ADMINISTRATIVE STRUCTURE

8.1 Does the worksite have a wellness committee?

8.2 Does the worksite set annual organizational objectives for wellness

8.3 Does the worksite contain references to improving/maintaining employee health in the organizational mission statement?

8.4 Does the worksite provide health education services (instruction, screening, etc.) to family members of employees?

8.5 Does the worksite have an individual responsible for delivery of a health promotion (wellness) program?

8.6 Did the worksite complete a needs assessment during the previous 24 months?

8.7 Did the worksite evaluate health promotion efforts during the previous 12 months?

8.8 Did the worksite provide general health enhancement messages to the employee population during the previous 12 months such as through posters, newsletters, brochures, videos or lectures, etc.?

8.9 Does the worksite maintain membership in a wellness coalition or health council?

8.10 Does the worksite provide management support for worksite health promotion during the previous 12 months by providing an annual message from the CEO supporting health promotion (personal address, memo, newsletter article, etc.) and providing managers with performance objectives related to worksite health?

8.11 Does the worksite have a program theme or logo?

8.12 Did the worksite provide management training seminars within the last 36 months on the importance of employee health promotion

8.13 Does the worksite provide policies to recruit and retain health oriented employees?

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9 ORGANIZATIONAL FOUNDATIONS

9.1 Did the worksite use some form of negotiated management by objective format between the employee and supervisor for determining workload (either through collective bargaining or individual negotiation)?

9.2 Did the worksite use a formal employee appraisal process for the supervisor to assess employee performance?

9.3 Does the worksite have a formal employee grievance procedure?

9.4 Does the worksite provide flexible work scheduling policies (flextime schedule/work at home)?

9.5 Does the worksite provide leave/vacation time allowances?

9.6 Does the worksite provide extended disability coverage or sick time allowances (e.g., sick banks)?

9.7 Does the worksite have a strategy to address dependent (child/elder) care?

9.8 Does the worksite subsidize the employee's health insurance by at least 50%?

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