Community Participant Emgagement Feedback Survey

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

CDC National Healthy Worksite Program
Community Participant Engagement Feedback Survey
Public reporting of this collection of information is estimated to average 10 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).
Respondents/Sources

Content

Timing/Frequency

Community Participants
(HR Directors in a random sample
of employers (~15/community
site)

Knowledge of
engagement activities;
Reasons for choosing
not to participate;
Current worksite health
program offerings;
Intent to participate in
training opportunities

Approx 2 months after the
end of recruitment activities
in each community site

Number of
Respondents
100

Time per Survey
10/60

Implementation: This is planned as a brief web survey of HR Directors of employers who were not selected to
participate in the National Healthy Worksite Program or did not choose to complete the certification process and
participate in the NHWP (a random sample of non-participating employers (~15 per community site),
administered approximately 2 months after the conclusion of the recruitment effort in each community site.
Introduction
Thank you for taking time today to help us better understand issues related to the National Healthy Worksite
(NHW) program. This survey asks about characteristics of your company and your exposure to information
about the National Healthy Worksite (NHW) program. This survey should take about 10 minutes to complete.
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 Research Triangle Institute International (RTI). RTI is an independent, non-profit
institute headquartered in Research Triangle Park, NC. RTI provides technical services to clients
worldwide. They are helping CDC evaluate the National Healthy Worksite (NHW) program.
You were asked to complete the survey because we want to learn more about companies that were not
selected or did not choose to complete the certification process and participate in the NHWP.
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 10 minutes.
There are no right or wrong answers or ideas—we want to hear about YOUR experiences and opinions.

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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 Dr. Laurie Cluff at RTI. Her toll-free number is 1-800-334-8571 x 6514. You
can also call RTI’s Office of Research Protection and Ethics toll-free at 1-866-214-2043.

The National Healthy Worksite Program, offered by the Centers for Disease Control and Prevention, is assisting
employers in establishing comprehensive workplace health programs for their employees. Employers from 7
communities across the country were eligible for intensive onsite support and expertise over a two-year period.

1. Do you remember seeing communications about the program or were you asked to participate in the National
Healthy Worksite program?
[1] Yes – [Continue to Question 2]
[2] No -- [Please go to Question 3]
[3] I don’t recall – [Please go to Question 3]
2. How did you learn about the opportunity to participate in the program?
(Please mark all that apply)
Yes

No

a. e-mail invitation

1

2

b. Letter/postcard

1

2

c.

1

2

d. In-person meeting

1

2

e. Information on a website or social
media (e.g., Facebook)
f. Colleague in another workplace

1

2

1

2

g. Webinar

1

2

h. Federal Register Notice

1

2

Method

i.

Telephone invitation

Other (Specify: _______________)

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3. Does your worksite currently have a worksite health program in place?
[1] Yes [Please go to Question 3a]
[2] No

[Please go to Question 5]

[3] I don’t know [Please go to Question 5]
3a. What wellness program elements are offered through your worksite health program?
Services
a. Health screenings
b. Health coaching
c. Wellness policies
d. Healthy food options available
e. On-site fitness facilities
f. Health education seminars (e.g., lunch-and-learns)
g. Walking groups, fitness challenges, and/or other social wellness
activities
h. Subsidized gym memberships
i. Integrated employee health plan benefit elements (e.g., payment
structure changes for healthy behavior)
j. Incentives for program participation

Yes

No

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

1

2

k. Other
(Specify): ____________________________________

3b. About what percentage of employees participate in at least one the elements of the health promotion
program?
[1] Less than 10 percent

[6] 50 – 59 percent

[2] 10 – 19 percent

[7] 60 – 69 percent

[3] 20 – 29 percent

[8] 70 – 79 percent

[4] 30 – 39 percent

[9] 80 – 89 percent

[5] 40 – 49 percent

[10] 90 percent or more

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4. Does your worksite have an employee(s) or resource(s) inside your organization who helps staff the program
(for example, serves as a health coordinator or member of a health coordination team)?
[1] Yes
[2] No
[3] I don’t know
5. Why do you think your worksite decided not to participate as a Program Participant in the National Healthy
Worksite Program? (Please select all that might apply).
Yes

No

a. We already offer a worksite health program

1

2

b. Management was not convinced the program was needed

1

2

c.

1

2

d. Management thought the program would take up too much
management and employee time

1

2

e. Management did not want to be involved with a government
program

1

2

f.

1

2

1

2

Services

Management thought the program cost too much

My worksite was interested, but did not meet the eligibility
criteria

g. My worksite was eligible, but was not selected to participate
h. Other (Specify: _______________)

6. Employers who are not receiving onsite intensive support as a National Health Worksite Program Participant
were eligible to participate in worksite wellness training opportunities. Did you participate in any National
Healthy Worksite Program in-person trainings or webinars? (Select all that apply.)
[1] Yes, I participated in one or more in-person training sessions
[2] Yes, I participated in one or more webinars
[3] No, but I intend to participate I in trainings or webinars in the future.
[4] I don’t remember
7. What size is your company?
[1] 1 – 100 employees
[2] 101 – 250 employees
[3] 251 – 500 employees
[4] More than 500 employees

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8. What industry best describes your worksite?
[1] Agriculture, Forestry and Fishing
[2] Mining
[3] Construction
[4] Manufacturing
[5] Transportation, Communications and Public Utilities
[6] Wholesale Trade
[7] Retail Trade
[8] Finance, Insurance, and Real Estate
[9] Services
[10] Public Administration
9. Where is your worksite? [drop down list of states or geographic regions]
10. What would make a worksite health program attractive to a workplace like yours? [open-ended]

THANK YOU!

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