1. I would buy healthy snacks at the worksite if they were available. (For example, low fat yogurt, low fat milk, dried fruit and nut mix, fresh fruit, pretzels, instead of candy, chips, cookies, cupcakes, etc.

   Definitely
   Some of the time
   Probably not too often
   Not at all

2. At some worksites, employees maintain a selection of healthy snacks separate from any on-site vending machines. Their "healthy snack bowl" has things like fresh fruit and single-serving packages of raisins, applesauce, cereals and nuts, all at a modest price (typically 25-75¢.) What is your reaction to this idea?

   I would be more likely to buy fresh fruit and nutritious snacks this way
   I am (still) more likely to use the vending machine (or local convenience store) for any snacks I purchase when at work
   I am (still) more likely to bring snacks from home and not purchase them at work
   Other, or don't know

 I would volunteer to help maintain a healthy snack selection set up by employees (does not involve paying for supplies.)

   Yes    No

3. Sometimes, employees come together in ad hoc interest groups to support each other in various activities. The groups are informal, and any employee is welcome to participate. Often however, people are not aware of them.

What kind of group might you participate with on an informal basis if you knew others shared your interest? (Check all that apply)

	Walking Stretching Meditation Nutrition Cooking	In-line skating Running Biking Hiking Basketball	Volleyball Weight loss Resistance training Yoga
	not interested

   other      

4. If the Wellness Committee wanted to get out information about their activities, or news and tips about healthy lifestyle choices, what would be your preferred way to get that information? (select one)

   a dedicated bulletin board
   weekly e-mail tips
   in a flyer distributed with paychecks
   on the intranet
   discussion at staff meetings

   other   

5. A lot of individuals are generally aware that good nutrition and regular physical activity are associated with health benefits .

 Are you able to get in as much physical activity as you feel is appropriate for your own better health?

   Yes   No   Don't know

 Do you find that you eat as nutritiously as you feel is appropriate for your own better health?

   Yes   No   Don't know

6. Have you recently given serious thought to making a personal lifestyle change related to better health? (For example, loose weight, change the kinds of foods you eat, become more physically active, reduce stress, stop smoking.)

   Yes, in the past year
   Yes, a year or more ago 
   No, not in recent memory

 If "yes" which one statement best fits for you?

   I didn't go any farther than to think about making a lifestyle change 
   I started to make some changes one or more times, but they didn't last more than a week or so 
   I made lifestyle changes that stuck for a few months or more, but I'm not following them anymore
   I made lifestyle changes that stuck for a few months or more, and I'm still following them

7. Do you think that good nutrition and regular physical activity can contribute to better productivity at work?

   Yes     No    Don't Know

8. Do you typically take regular breaks during the day? (i.e., plan for breaks most days)

   Yes, most "typical" days   No, I usually don't take a break

 If "yes", what breaks do you most often take?  (Check all that apply)

   Morning "coffee" break
   Afternoon break
   Lunch    If yes for lunch, about how much time do you usually take?
   under 30 minutes    ~ 30 min.   ~ 45 min.   ~ an hour

 If "no", you don't take breaks, why not? (Check all that apply)

pressure to get work done I eat at my desk feel that chatting with others during work takes up my "break" time		need to catch up on work just don't want to other

 Would you be more willing to take breaks if you knew that your workplace encouraged it?

   Yes   No

9. Making important lifestyle changes is rarely easy for anyone. Still, some people have a better chance for success when they work with a buddy or in a group. Others have a better chance for success working by themselves. Which style better fits you?

   I'm more likely to succeed with a buddy or in a group (either family, friends, or coworkers)
   I'm more likely to succeed when I work on my own
   Don't know
   I don't need to make any lifestyle changes

 Would you be more likely to participate in a Wellness Program if there were incentives and you have an opportunity to win something of value?

   Most likely, Yes  Probably Not

10. Do you have any particular expertise or health related specialty that you could share with a group?

   Yes  No

 If "yes" what is it?

11. As part of their wellness program, some worksites get books, recipes, videos, and other items for use by employees who want to learn more about health and wellness issues and choices. Would you use this kind of resource center if available?

   Definitely, I would use it
   It sounds interesting and I'd try to use it
   It sounds interesting, but I probably wouldn't use it
   It's not something I would use at all
   Don't know or "other"
(specify if "other")

12. Would you be willing to join the Wellness Committee or a program team?

   Yes  No

13. If you have additional comments, please let us know here!
   

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