Organizational Assessment (Employer)

Form Approved
OMB No. 0920-XXXX
Exp. Date: XX-XX-XXXX

CDC National Healthy Worksite Program
Organizational Assessment
Public reporting of this collection of information is estimated to average 30 minutes per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is
not required to respond to a collection of information unless it displays a currently valid OMB control number.
Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74,
Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).
Informed Consent
Before you get started, we’d like need to give you some more information to help you decide whether or not you
would like to participate.
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This project is funded by the Centers for Disease Control and Prevention. Many parts of the project are
being managed by Viridian Health Management (Viridian). Viridian is a private health and wellness
company based in Phoenix, AZ. Viridian provides flexible, customized solutions to building comprehensive
healthy worksite programs. They are helping CDC implement the National Healthy Worksite (NHW)
program.
You were asked to participate because your worksite is participating in the National Healthy Worksite
(NHW) program as a benefit to employees. All employers in the NHW program will be asked to complete
this questionnaire at the beginning and at the end of the NHW program.
Your participation in this survey is voluntary. In the course of this survey, you may refuse to answer
specific questions. You may also choose to end the discussion at any time.
The survey is designed to take about 30 minutes.
There are no right or wrong answers or ideas—we want to hear about YOUR experiences and opinions.
All of the comments you provide will be maintained in a secure manner. We will not disclose your
responses or anything about you unless we are compelled by law. Your responses will be combined with
other information we receive and reported in the aggregate as feedback from the group. In our project
reports, your name will not be linked to the comments you provide in this discussion.
CDC is authorized to collect information for this project under the Public Health Services Act.
There are no personal risks or personal benefits to you for participating in this discussion.
We are interested in your comments so that we can improve the NHW program for future participants.
Please feel free to contact [INSERT WORKSITE NHWP PROGRAM MANAGER]. [HIS/HER] number is
[INSERT TEL #]. You can also call Viridian Health Management toll-free at 1-877-486-0140.

1

Instructions
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Answer “yes” or “no” for each question on the tool. All questions should be answered consistently with your
worksite practices and programs that are current or that have been in place within the last 12 months.

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All questions should be answered consistently with your worksite practices and programs that are current or
that have been in place within the last 12 months.

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There are 15 sections to the tool; you may complete each section in separate sittings and in any order.
Individual scores can be tallied for each section and combined for an overall score once all sections are
completed. The entire survey will take approximately 30 minutes to complete.

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We recommend that you form a small team, representing different organizational units to complete this survey
together. A team-based approach will allow for more accurate responses, increase ownership and
involvement amongst the team, and decrease effort for any single team member. Since a strong knowledge of
your organization and its health promotion program(s) is recommended to accurately complete the tool, strive
to pick team members who occupy the following positions:
o Members of a worksite health promotion committee
o Human resource managers
o Health benefits managers
o Health education staff
o Occupational nurses
o Medical directors
o Wellness directors
o Health promotion coordinators
o Building facilities managers

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Scan each section before attempting to respond. Answers to most questions are readily available following a
review of organizational health policies (e.g., a policy handbook), benefit plan designs, interviews with key
stakeholders, and direct observation. In some cases, answers may not be immediately obvious to the person
assigned to complete the section. If you do not know the answer to the question, leave the box empty, and
then engage others at the worksite to help you answer it.

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Some questions ask you to describe your health insurance plan. If your organization offers more than one
health insurance option, refer to the health insurance plan with the highest enrollment.

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Throughout the survey, questions refer to “health promotion” at your worksite. This is also known as “worksite
wellness” or “wellness programs”.

Once completed, you can give it to [INSERT WORKSITE NHWP COMMUNITY DIRECTOR]. If you have any
questions, Please feel free to contact [INSERT WORKSITE NHWP COMMUNITY DIRECTOR]. [HIS/HER]
number is [INSERT TEL #]. You can also call Viridian Health Management toll-free at 1-877-486-0140.

2

Organizational Supports
During the past 12 months, did your worksite:

Yes

1. Conduct an employee needs and interests assessment for planning health
promotion activities? Answer “yes” if, for example, your organization
administers focus groups or employee satisfaction surveys to assess your
employee health promotion program(s). Answer “no” if your organization
administers general surveys that do not assess your employee health
promotion program(s).
2. Conduct employee health risk appraisals/assessments through vendors, onsite
staff, or health plans and provide individual feedback plus health education?
Answer “yes” if, for example, your organization provides individual feedback
through written reports, letters, or one-on-one counseling.
3. Demonstrate organizational commitment and support of worksite health promotion
at all levels of management? Answer “yes” if, for example, all levels of
management participate in activities, communications are sent to employees
from senior leaders, the worksite supports performance objectives related to
healthy workforce, and/or program ownership is shared with all staff levels.
4. Use and combine incentives with other strategies to increase participation in health
promotion programs? Answer “yes” if, for example, your organization offers
incentives such as gift certificates, cash, paid time off, product or service
discounts, reduced health insurance premiums, employee recognition, or
prizes.
5. Use competitions when combined with additional interventions to support
employees making behavior changes? Answer “yes” if, for example, your
organization offers walking or weight loss competitions.
6. Promote and market health promotion programs to employees? Answer “yes” if,
for example, your worksite’s health promotion program has a brand name or
logo, uses multiple channels of communication, or sends frequent
messages.
7. Use examples of employees role modeling appropriate health behaviors or
employee health-related "success stories" in the marketing materials?
8. Tailor some health promotion programs and education materials to the language,
literacy levels, culture, or readiness to change of various segments of the
workforce? Answer “no” if you do not perceive a need for your organization
to tailor its health promotion programs and education materials to any
specific group(s).
9. Have a health promotion committee?
10. Have a paid health promotion coordinator whose job (either part-time of full-time)
is to implement a worksite health promotion program? Answer “yes” if
implementing the employee health promotion program(s) at your worksite is
included in a paid staff member’s job description or performance
expectations.
11. Have a champion(s) who is a strong advocate for the health promotion program?
12. Have an annual budget or receive dedicated funding for health promotion
programs?
3

No

13. Set annual organizational objectives for health promotion?
14. Include references to improving/maintaining employee health in the business
objectives or organizational mission statement? Answer “no” if your
organization’s business objectives or mission statement only reference
occupational health and safety, without reference to improving the
workforce’s health.
15. Conduct ongoing evaluations of health promotion programming that use multiple
data sources? Answer “yes” if, for example, your organization collects data
on employee health risks, medical claims, employee satisfaction or
organizational climate surveys.
16. Make any health promotion programs available to family members?
17. Provide flexible work scheduling policies? Answer “yes” if, for example, policies
allow for flextime schedules and work at home.
18. Engage in other health initiatives throughout the community and support employee
participation and volunteer efforts? Answer “yes “if, for example, your
organization supports participation in community events and school-based
efforts, such as corporate walks, collaborate with state and local advocacy
groups, health and regulatory organizations, and coalitions.

4

Tobacco Control
During the past 12 months, did your worksite:

Yes

1. Have a written policy banning tobacco use at your worksite? Answer “yes” if your
worksite adheres to a state-wide, county-wide, or city-wide policy banning
tobacco use in the workplace.
2. Actively enforce a written policy banning tobacco use? Answer “yes” if, for
example, your worksite posts signs, does not have ashtrays, or communicates
this written policy banning tobacco use through various channels at your
worksite.
3. Display signs (including ‘no smoking’ signs) with information about your tobacco-use
policy?
4. Refer tobacco users to a state or other tobacco cessation telephone quit line?
Answer “yes” if, for example, your worksite refers tobacco users to 1-800QUIT NOW or smokefree.gov
5. Provide health insurance coverage with no or low out-of-pocket costs for
prescription tobacco cessation medications including nicotine replacement?
Answer “yes” if, for example, your organization provides coverage for
inhalers, nasal sprays, bupropion (e.g., Zyban) and varenicline (e.g., Chantix).
6. Provide health insurance coverage with no or low out-of-pocket costs for FDAapproved over-the-counter nicotine replacement products? Answer “yes” if, for
example, your organization provides coverage for nicotine replacement gum,
patches, or lozenges.
7. Provide or promote free or subsidized tobacco cessation counseling? Answer “yes”
if these programs are provided on- or off-site; in group or individual settings;
through vendors, on-site staff, health insurance plans/programs, community
groups, or other practitioners.
8. Inform employees about health insurance coverage or programs that include
tobacco cessation medication and counseling?
9. Provide incentives for being a current non-user of tobacco and for current tobacco
users that are currently involved in a cessation class or actively quitting? Answer
“yes” if, for example, your organization provides discounts on health
insurance, increases in disability payments or additional life insurance for
non-smokers and tobacco users who are actively trying to quit.
10. Do not allow sale of tobacco products on company property? Answer “yes” if, for
example, your worksite does not sell tobacco products on company property
in vending machines or through on-site vendors. of tobacco products on
company property (e.g., in vending machines or by vendors).

5

No

Nutrition
During the past 12 months, did your worksite:

Yes

1. Provide places to purchase healthy food and beverages? Answer “yes” if, for example,
your worksite provides vending machines, cafeterias, snack bars, or other purchase
points. IF NO, PLEASE SKIP TO QUESTION 8.
2. Have a written policy or formal communication that makes healthier food and beverage
choices available in cafeterias or snack bars? Answer “yes” if, for example, the policy
or formal communication makes vegetables, fruits, 100% fruit juices, whole grain
items and trans-fat free/low-sodium snacks available in cafeterias or snack bars.
3. Have a written policy or formal communication that makes healthier food and beverage
choices available in vending machines? Answer “yes” if, for example, the policy or
formal communication makes vegetables, fruits, 100% fruit juices, whole grain items
and trans-fat free/low-sodium snacks available in vending machines.
4. Make most (more than 50%) of the food and beverage choices available in vending
machines, cafeterias, snack bars, or other purchase points be healthy food items? Answer
“yes” if the healthy foods are items such as skim milk, 1% milk, water, unsweetened
flavored water, 100% fruit juice, low-fat and low-sodium snacks, or fresh fruit.
5. Provide nutritional information (beyond standard nutrition information on labels) on sodium,
calories, trans-fats, or saturated fats for foods and beverages sold in worksite cafeterias,
snack bars, or other purchase points?
6. Identify healthier food and beverage choices with signs or symbols? Answer “yes” if, for
example, your worksite puts a heart next to a healthy item near vending machines,
cafeterias, snack bars, or other purchase points.
7. Subsidize or provide discounts on healthier foods and beverages offered in vending
machines, cafeterias, snack bars, or other purchase points?
8. Have a written policy or formal communication which makes healthier food and beverage
choices available during meetings when food is served? Answer “yes” if, for example,
the policy or formal communication makes vegetables, fruits, 100% fruit juices,
whole grain items or trans-fat free/low-sodium snacks available during meetings.
9. Provide employees with food preparation and storage facilities? Answer “yes” if your
worksite provides a microwave oven, sink, refrigerator, and/or kitchen.
10. Offer or promote an onsite or nearby farmers market where fresh fruits and vegetables are
sold?
11. Provide brochures, videos, posters, pamphlets, newsletters, or other written or online
information that address the benefits of healthy eating? Answer “yes” if these health
promotion materials address the benefits of healthy eating as a single health topic or
if the benefits of healthy eating are included with other health topics.
12. Provide educational seminars, workshops, or classes on nutrition? Answer “yes” if these
sessions address nutrition as a single health topic or if nutrition is included with
other health topics. These sessions can be provided in-person or online; onsite or
offsite; in group or individual settings; through vendors, on-site staff, health
insurance plans/programs, community groups, or other practitioners.
13. Provide free or subsidized lifestyle self-management programs that include advice or tools
on healthy eating? Answer “yes” if these programs are provided in-person or online;
onsite or offsite; in group or individual settings; through vendors, on-site staff,
health insurance plans/programs, community groups, or other practitioners.

6

No

Physical Activity
During the past 12 months, did your worksite:

Yes

1. Provide an exercise facility on-site?
2. Subsidize or discount the cost of onsite and/or offsite exercise facilities?
3. Provide environmental supports for recreation or exercise? Answer “yes” if, for
example, your worksite provides trails or a track for walking/jogging, maps of
suitable walking routes, bicycle racks, open space designated for recreation
or exercise, a shower and changing facility.
4. Post signs at elevators, stairwell entrances/exits and other key locations that
encourage employees to use the stairs? Answer “no” if your worksite is located
in a one-story building.
5. Provide organized individual or group physical activity programs for employees
(other than the use of an exercise facility)? Answer “yes” if, for example, your
worksite provides walking or stretching programs, group exercise, or weight
training.
6. Provide brochures, videos, posters, pamphlets, newsletters, or other written or
online information that address the benefits of physical activity? Answer “yes” if
these health promotion materials address the benefits of physical activity as
a single health topic or if the benefits of physical activity are included with
other health topics.
7. Provide educational seminars, workshops, or classes on physical activity? Answer
“yes” if these sessions address physical activity as a single health topic or if
physical activity is included with other health topics. These sessions can be
provided in-person or online; onsite or offsite; in group or individual settings;
through vendors, on-site staff, health insurance plans/programs, community
groups, or other practitioners.
8. Provide or subsidize physical fitness assessments, follow-up counseling, and
exercise recommendations either onsite or through a community exercise facility?
9. Provide free or subsidized lifestyle self-management programs that include advice
on physical activity? Answer “yes” if these programs are provided in-person or
online; onsite or offsite; in group or individual settings; through vendors, onsite staff, health insurance plans/programs, community groups, or other
practitioners.

7

No

Weight Management
During the past 12 months, did your worksite:

Yes

1. Provide free or subsidized body composition measurement, such as height and
weight, Body Mass Index (BMI) scores, or other body fat assessments (beyond
HRAs) followed by directed feedback and/or clinical referral when appropriate?
2. Provide brochures, videos, posters, pamphlets, newsletters, or other written or
online information that address the risks of overweight or obesity? Answer “yes” if
these health promotion materials address the risks of overweight or obesity
as a single health topic or if the risks of overweight or obesity are included
with other health topics.
3. Provide educational seminars, workshops, or classes on weight management?
Answer “yes” if these sessions address weight management as a single
health topic or if weight management is included with other health topics.
These sessions can be provided in-person or online; onsite or offsite; in
group or individual settings; through vendors, on-site staff, health insurance
plans/programs, community groups, or other practitioners.
4. Provide free or subsidized one-on-one or group lifestyle counseling for employees
who are overweight or obese? Answer “yes” if these programs are provided inperson or online; onsite or offsite; in group or individual settings; through
vendors, on-site staff, health insurance plans/programs, community groups,
or other practitioners.
5. Provide free or subsidized lifestyle self-management programs that include advice
or tools on weight management? Answer “yes” if these programs are provided
in-person or online; onsite or offsite; in group or individual settings; through
vendors, on-site staff, health insurance plans/programs, community groups,
or other practitioners.

8

No

Stress Management
During the past 12 months, did your worksite:

Yes

1. Provide dedicated space where employees can engage in relaxation activities, such
as meditation, yoga, or biofeedback?
2. Sponsor or organize social events throughout the year? Answer “yes” if, for
example, your worksite sponsors or organizes team building events, company
picnics, holiday parties, or employee sports teams.
3. Provide stress management programs? Answer “yes” if these programs address
stress management as a single health topic or if stress management is
included with other health topics. Answer “yes” if these programs are
provided in-person or online; onsite or offsite; in group or individual settings;
through vendors, on-site staff, health insurance plans/programs, community
groups, or other practitioners.
4. Provide work-life balance/ life-skills programs? Answer “yes” if, for example, your
worksite provides eldercare, childcare, referrals, tuition reimbursement, or
other programs that are offered through vendors, onsite staff, or employee
assistance programs.
5. Provide training for managers on identifying and reducing workplace stress-related
issues? Answer “yes” if, for example, your worksite provides training on
performance reviews, communication, personnel management, assertiveness,
time management, or conflict resolution.
6. Provide opportunities for employee participation in organizational decisions
regarding workplace issues that affect job stress? Answer “yes” if, for example,
your worksite provides opportunities for employees to participate in decisions
about work processes and environment, work schedules, participative
problem-solving, and management of work demands.

9

No

Depression
During the past 12 months, did your worksite:

Yes

1. Provide free or subsidized clinical screening for depression (beyond HRAs) followedby directed feedback and/or clinical referral when appropriate? Answer “yes” if
these services are provided directly through your organization or indirectly
through a health insurance plan.
2. Provide access to online or paper self-assessment depression screening tools?
3. Provide brochures, videos, posters, pamphlets, newsletters, or other written or online
information that address depression? Answer “yes” if these health promotion
materials address depression as a single health topic or if depression is
included with other health topics.
4. Provide educational seminars, workshops, or classes on preventing and treating
depression? Answer “yes” if these sessions address depression as a single
health topic or if depression is included with other health topics. These
sessions can be provided in-person or online; onsite or offsite; in group or
individual settings; through vendors, on-site staff, health insurance
plans/programs, community groups, or other practitioners.
5. Provide one-on-one or group lifestyle counseling for employees with depression?
Answer “yes” if these programs are provided in-person or online; onsite or
offsite; in group or individual settings; through vendors, on-site staff, health
insurance plans/programs, community groups, or other practitioners.
6. Provide training for managers on depression in the workplace? Answer “yes” if, for
example, your worksite provides managers with training on how to recognize
depression, productivity/safety issues, and company/community resources for
managing depression.
7. Provide health insurance coverage with no or low out-of-pocket costs for depression
medications and mental health counseling?

10

No

High Blood Pressure
During the past 12 months, did your worksite:

Yes

1. Provide free or subsidized blood pressure screening (beyond HRAs) followed
by directed feedback and/or clinical referral when appropriate?
2. Provide brochures, videos, posters, pamphlets, newsletters, or other written or
online information that address the risks of high blood pressure? Answer “yes”
if these health promotion materials address the risks of high blood
pressure as a single health topic or if the risks of high blood pressure are
included with other health topics.
3. Provide educational seminars, workshops, or classes on preventing and
controlling high blood pressure? Answer “yes” if these sessions address
preventing or controlling high blood pressure as a single health topic or if
preventing and controlling high blood pressure are included with other
health topics. These sessions can be provided in-person or online; onsite
or offsite; in group or individual settings; through vendors, on-site staff,
health insurance plans/programs, community groups, or other
practitioners.
4. Provide one-on-one or group lifestyle counseling and follow-up monitoring for
employees with high blood pressure or pre-hypertension? Answer “yes” if
these programs are provided in-person or online; onsite or offsite; in
group or individual settings; through vendors, on-site staff, health
insurance plans/programs, community groups, or other practitioners.
5. Provide free or subsidized lifestyle self-management programs for blood
pressure control and prevention? Answer “yes” if these programs are
provided in-person or online; onsite or offsite; in group or individual
settings; through vendors, on-site staff, health insurance plans/programs,
community groups, or other practitioners.
6. Make blood pressure monitoring devices available with instructions for
employees to conduct their own self assessments?
7. Provide health insurance coverage with no or low out-of-pocket costs for blood
pressure control medications?

11

No

High Cholesterol
During the past 12 months, did your worksite:

Yes

1. Provide free or subsidized cholesterol screening (beyond HRAs) followed by
directed feedback and/or clinical referral when appropriate?
2. Provide brochures, videos, posters, pamphlets, newsletters, or other written or
online information that address the risks of high cholesterol? Answer “yes” if
these health promotion materials address the risks of high cholesterol as
a single health topic or if the risks of high cholesterol are included with
other health topics.
3. Provide educational seminars, workshops, or classes on preventing and
controlling high cholesterol? Answer “yes” if these sessions address
preventing and controlling high cholesterol as a single health topic or if
preventing and controlling high cholesterol are included with other health
topics. These sessions can be provided in-person or online; onsite or
offsite; in group or individual settings; through vendors, on-site staff,
health insurance plans/programs, community groups, or other
practitioners.
4. Provide one-on-one or group lifestyle counseling and follow-up monitoring for
employees who have high cholesterol? Answer “yes” if these programs are
provided in-person or online; onsite or offsite; in group or individual
settings; through vendors, on-site staff, health insurance plans/programs,
community groups, or other practitioners.
5. Provide free or subsidized lifestyle self-management programs for
cholesterol/lipid control? Answer “yes” if these programs are provided inperson or online; onsite or offsite; in group or individual settings; through
vendors, on-site staff, health insurance plans/programs, community
groups, or other practitioners.
6. Provide health insurance coverage no or low out-of-pocket costs for
cholesterol/lipid control medications?

12

No

Diabetes
During the past 12 months, did your worksite:

Yes

1. Provide free or subsidized pre-diabetes and diabetes risk factor assessment
(beyond HRAs) and feedback, followed by blood glucose screening and/or
clinical referral when appropriate?
2. Provide brochures, videos, posters, pamphlets, newsletters, or other written or
online information that address the risks of diabetes? Answer “yes” if these
health promotion materials address the risks of diabetes as a single
health topic or if the risks of diabetes are included with other health
topics.
3. Provide educational seminars, workshops, or classes on preventing and
controlling diabetes? Answer “yes” if these sessions address preventing
and controlling diabetes as a single health topic or if preventing and
controlling diabetes are included with other health topics. These
sessions can be provided in-person or online; onsite or offsite; in group
or individual settings; through vendors, on-site staff, health insurance
plans/programs, community groups, or other practitioners.
4. Provide one-on-one or group lifestyle counseling and follow-up monitoring for
employees who have abnormal blood glucose levels (pre-diabetes or
diabetes)? Answer “yes” if these programs are provided in-person or
online; onsite or offsite; in group or individual settings; through
vendors, on-site staff, health insurance plans/programs, community
groups, or other practitioners.
5. Provide free or subsidized lifestyle self-management programs for diabetes
control? Answer “yes” if these programs are provided in-person or
online; onsite or offsite; in group or individual settings; through
vendors, on-site staff, health insurance plans/programs, community
groups, or other practitioners.
6. Provide health insurance coverage with no or low out-of-pocket costs for
diabetes medications and supplies for diabetes management (glucose test
strips, needles, monitoring kits)?

13

No

Signs and Symptoms of Heart Attack and Stroke
During the past 12 months, did your worksite:

Yes

1. Have posters or flyers in the common areas of your worksite (such as bulletin
boards, kiosks, break rooms) that identify the signs and symptoms of a heart
attack and also convey that heart attacks are to be treated as emergencies?
2. Have posters or flyers in the common areas of your worksite (such as bulletin
boards, kiosks, break rooms) that identify the signs and symptoms of a stroke
and also convey that strokes are to be treated as emergencies?
3. Provide any other information on the signs and symptoms of heart attack
through emails, newsletters, management communications, websites, seminars
or classes?
4. Provide any other information on the signs and symptoms of stroke through
emails, newsletters, management communications, websites, seminars or
classes?

14

No

Emergency Response to Heart Attack and Stroke
During the past 12 months, did your worksite:

Yes

1. Have an emergency response plan that addresses acute heart attack and
stroke events?
2. Have an emergency response team for medical emergencies?
3. Offer access to a nationally-recognized training course on Cardiopulmonary
Resuscitation (CPR) that includes training on Automated External Defibrillator
(AED) usage?
4. Have a policy that requires an adequate number of employees per floor, work
unit, or shift, in accordance with pertinent state and federal laws, to be certified
in CPR/AED?
5. Have one or more functioning AEDs in place? IF NO, PLEASE PROCEED TO
THE NEXT TOPIC.
6. Have an adequate number of AED units such that a person can be reached
within 3-5 minutes of collapse?
7. Identify the location of AEDS with posters, signs, markers, or other forms of
communication other than on the AED itself?
8. Perform routine maintenance or testing on all AEDs?
9. Provide information to your local community Emergency Medical Service
providers so they are aware that your worksite has an AED in place to faciliate
emergency response?

15

No

Lactation Support
During the past 12 months, did your worksite:

Yes

1. Have a written policy on breastfeeding? Answer “yes” if the policy is included
as a component of other employee policies or is a separate policy related to
breastfeeding.
2. Provide a private space (other than a restroom) that may be used by an
employee to express breast milk?
3. Provide access to a breast pump at the worksite?
4. Provide flexible break times to allow mothers to pump breast milk? Answer
“yes” if flexible break times are provided, whether paid or unpaid.
5. Provide free or subsidized breastfeeding support groups or educational classes?
Answer “yes” if these sessions address breastfeeding as a single health
topic or if breastfeeding is included with other health topics. These
sessions can be provided in-person or online; onsite or offsite; in group or
individual settings; through vendors, on-site staff, health insurance
plans/programs, community groups, or other practitioners.
6. Offer paid maternity leave, separate from any other accrued leave? Answer
“no” if employees may take paid maternity leave using only accrued leave
such as sick or annual leave time.

16

No

Community Resources
During the past 12 months, did your worksite:

Yes

No

1. Provide employees with health related information, programs, or resources from any of the following
organizations? (Respond YES to all that apply)
1A. Local public health agency
1B. Health insurance plan
1C. Health management or wellness provider / vendor
1D. Workers compensation provider
1E. Health Related Organizations (American Heart Association, American Cancer
Society, etc).
1F. Insurance broker
1G. Hospital
1H. YMCA
1I. Community Organization or Business Group (Wellness Council, Chamber of
Commerce or other business group)
1J. Other
2. Receive technical support (guidance, advise, training, direction) from any of the following
organizations related to development of a worksite wellness program? (Respond YES to all that
apply)
2A. Local public health agency
2B. Health insurance plan
2C. Health management or wellness provider / vendor
2D. Workers compensation provider
2E. Health Related Organizations (American Heart Association, American Cancer
Society, etc).
2F. Insurance broker
2G. Hospital
2H. YMCA
2I. Community or Business Organization (Wellness Council, Chamber of Commerce
or other business group)
2J. Other
3. Participate in any Community Coalitions focused on health and / or business and
community partnerships?

17

Occupational Health and Safety
During the past 12 months, did your worksite:

Yes

1. Include references to improving/maintaining job health and safety in the business
objectives or organizational mission statement?
2. Have a written injury and illness prevention program?
3. Provide the means for employees to easily voice safety concerns or suggestions?
4. Employ an occupational health and safety professional?
5. Encourage reporting of injuries and near misses? Answer “yes” if there is written
and verbal encouragement to report all injuries and illnesses, and “no” if
workers are discouraged from reporting through awards or programs based on
no injuries.
6. Provided opportunities for employee input on hazards and solutions? Answer “yes”
if, for example, there were all-hands meetings, tool box meetings, surveys, or
focus groups for discovering and solving job health and safety issues.
7. Have a program to investigate the cause of injuries or illnesses? Answer “yes” if,
for example, all accidents are investigated to determine possible
environmental causes such as conducting a root cause analysis.
8. Are there written materials about health and safety at work to educate employees?
Answer “yes” if, for example, there are health and safety newsletters or
factsheets provided to employees.
9. Do all new workers get training on how to be safe on the job?
10. Is there coordination between health and safety administrators and health promotion
and wellness professionals in planning activities for employees?
11. Have the following policies or benefits for employees been in place:
11A. Paid time off (PTO) for days or hours specifically due to sickness/illness of
employees or dependents (non-exempt employees).
11B. Paid vacation time or personal days or hours (non-exempt employees).
11C. If Yes to #11A and #11B above, does your worksite track and record this Paid
time off (PTO) separately?
11D. Company paid short-term disability
11E. Company paid long-term disability

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No