All Employee Survey

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

CDC National Healthy Worksite Program (NHWP)
All Employee Survey
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).
Introduction
This survey asks about your perceptions of your work environment, working conditions, and the attitudes of
your supervisor and coworkers that support a healthy worksite culture. Our task is to provide the Centers for
Disease Control and Prevention (CDC) with an evaluation that will further CDC’s understanding of worksite
cultural factors that influence employee health behaviors and health outcomes.
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.
•

•

•
•
•
•

•
•
•

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 employees at your worksite 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
To make sure that health-related information and programs are tailored to affect your health problems and
concerns, we are asking each employee to fill out this survey. DO NOT write your name on this survey.
When you have completed this survey, please seal it in the envelope provided and place it in one of the collection
boxes located throughout your worksite by [INSERT DATE] or give it [INSERT WORKSITE NHWP PROGRAM
MANAGER]. If you have any questions, Please feel free to contact [INSERT WORKSITE NHWP PROGRAM
MANAGER]. [HIS/HER] number is [INSERT TEL #].
Thank you very much for your participation.

Employer Name:

Survey Date:

To what extent do you agree with the following statements?
Q#

Question

Response

1

In this facility, management considers
workplace health and safety to be
important.

Strongly
disagree

Disagree

Agree

Strongly agree

2

My supervisor understands and
supports my family and other personal
responsibilities.

Strongly
disagree

Disagree

Agree

Strongly agree

3

On my job, I have very little freedom
to decide how I do my work.

Strongly
disagree

Disagree

Agree

Strongly agree

4

My job allows me to make a lot of
decisions on my own

Strongly
disagree

Disagree

Agree

Strongly agree

5

I have enough time to get the job done Strongly
disagree
My job requires working very hard
Strongly
disagree
The people I work with take a personal Strongly
interest in me
disagree

Disagree

Agree

Strongly agree

Disagree

Agree

Strongly agree

Disagree

Agree

Strongly agree

8

The people I work with can be relied
on when I need help

Strongly
disagree

Disagree

Agree

Strongly agree

9

My supervisor is concerned about the
welfare of those under him or her

Strongly
disagree

Disagree

Agree

Strongly agree

10

My supervisor is helpful in getting the
job done

Strongly
disagree

Disagree

Agree

Strongly agree

11

My job requires me to be creative

Strongly
disagree

Disagree

Agree

Strongly agree

6
7

2

To what extent do you agree with the following statements?
Q#

Question

Response

12

My job requires a high level of skill

Disagree

Agree

Strongly agree

13

My job requires me to do repeated
lifting, pushing, pulling or bending

Strongly
disagree
Strongly
disagree

Disagree

Agree

Strongly agree

14

My job regularly requires me to
perform repetitive or forceful hand
movements

Strongly
disagree

Disagree

Agree

Strongly agree

Disagree

Neutral

Agree

Strongly
agree

To what extent do you agree with the following statements?
Q#
Question
Response
15
All employee concerns are heard
Strongly
before job decisions are made.
disagree
16

Job decisions are applied consistently
to all affected employees.

Strongly
disagree

Disagree

Neutral

Agree

Strongly
agree

17

You would be taken seriously if you
complained about disrespectful
treatment.

Strongly
disagree

Disagree

Neutral

Agree

Strongly
agree

18

Respectful treatment is the norm in
your unit/work group.

Strongly
disagree

Disagree

Neutral

Agree

Strongly
agree

19

My job duties often interfere with my
ability to comply with safety
regulations.

Strongly
disagree

Disagree

Neutral

Agree

Strongly
agree

Please answer the following questions.
Q#
Question
20
How often do things going on at work
make you feel tense and irritable at
home?

Response
Never

Occasionally

Sometimes

Often

Most of
the
time

21

Never

Occasionally

Sometimes

Often

Most of
the
time

How often do things going on at home
make you feel tense and irritable on
the job?

3

Please rate the following in a scale of 1-10.
Q#
Question
Response
22
Overall, how safe do you think your
workplace is (1 -extremely unsafe to
1
2
3
4
5
6
7
8
9
10
10- extremely safe)
23
Overall, how supportive is your
company of your personal health,
1
2
3
4
5
6
7
8
9
10
from (1 - extremely unsupportive to 10
- extremely supportive)?
For the following questions, please think about your work on YOUR CURRENT MAIN JOB. Assume that your work
ability at its best has a value of 10 points.
24

How many points would you give your
CURRENT ABILITY TO WORK? (0 means
that you cannot work at all; 10 means
0
1
2
3
4
5
6
7
8
9
10
your work ability is currently at its
lifetime best)?
25
Thinking about the physical demands
of your job, how do you rate your
current ability to meet those demands
0
1
2
3
4
5
6
7
8
9
10
(0 means that you cannot work at all;
10 means your work ability is currently
at its lifetime best)?
26
Thinking about the mental demands of
your job, how do you rate your current
ability to meet those demands (0
0
1
2
3
4
5
6
7
8
9
10
means that you cannot work at all; 10
means your work ability is currently at
its lifetime best)?
27
Thinking about the interpersonal
demands of your job, how do you rate
your current ability to meet those
0
1
2
3
4
5
6
7
8
9
10
demands (0 means that you cannot
work at all; 10 means your work ability
is currently at its lifetime best)?
Please rate how you feel about each of the following statements: "My employer has provided me with the opportunity
to": (Please check 1 box for each item below).
Q#
Question
Response
28
Strongly disagree
Disagree
Neutral
Agree
Strongly
agree
a. Be physically active
b. Eat a healthy diet
c. Live tobacco free
d. Manage my stress
e. Work safely
4

To what extent do you agree with the following statements?
Q#
Question
Response
29
Many of my coworkers engage in
Strongly disagree
unhealthy behaviors
30
If my health gets worse, my coworkers Strongly disagree
would support my recovery
31
My coworkers would support my use
Strongly disagree
of sick days for illness or mental health
32
33

34

35
36

Disagree

Neutral

Agree

Disagree

Neutral

Agree

Disagree

Neutral

Agree

Strongly
agree
Strongly
agree
Strongly
agree

My supervisor encourages healthy
behaviors
My organization encourages me to
make suggestions about employee
safety, health and well-being
Overall I would recommend working
with this organization to my family and
friends.
I often think about quitting my job.

Strongly disagree

Disagree

Neutral

Agree

Strongly
agree
Strongly
agree

Strongly disagree

Disagree

Neutral

Agree

Strongly disagree

Disagree

Neutral

Agree

Strongly
agree

Strongly disagree

Disagree

Neutral

Agree

I will probably look for a new job
during the next year.

Strongly disagree

Disagree

Neutral

Agree

Strongly
agree
Strongly
agree

Please answer the following questions.
Q#
37
38

39

40

Questions
Response
All in all, how satisfied would you say
Very Satisfied
Satisfied
Dissatisfied
Very Dissatisfied
you are with your job?
How much time do you spend
< 15 minutes
15-30
30 - 60
60 - 90
> 90
traveling to and from work each day
minutes
minutes
minutes
minutes
(roundtrip)?
What is the highest grade or year of school that you have completed (Check One):
Never attended school or only attended kindergarten
Grades 1 through 8 (elementary)
Grades 9 through 11 (some high school)
Grade 12 or GED (high school graduate)
College 1 year to 3 years (some college or technical school)
College 4 years or more (College graduate)
What is your current marital status (Check One)?
Married
Divorced
Widowed
Separated
Never married
Member of an unmarried couple

5

Please answer the following questions.
41
What is your level of supervisory responsibility (Check One)?
No supervisory responsibility
Team leader
First line supervisor
Manager
Executive
42a
Are you Hispanic or Latino?
Yes
No
Don’t Know / Not Sure
42b
Which one of these groups would you say best represents your race?
White
Black or African American
Asian
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Other (Specify):
43
Date of Birth
mm/dd/yyyy
44
Gender
Male

Thank You!

6

Female