Satisfaction Survey (Employee)

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

CDC National Healthy Worksite Program
Satisfaction Survey
Public reporting of this collection of information is estimated to average 15 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 satisfaction with the National Healthy Worksite program at your worksite. Our
task is to provide the Centers for Disease Control and Prevention (CDC) with an evaluation that will further
CDC’s understanding of how effectively various program components were implemented based on employee
satisfaction.
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 employees at your worksite will be asked to complete this
questionnaire each quarter (every 3 months).
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 15 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:

Q#

Healthy Worksite Program Quarterly
Survey:

Strongly
agree

1

I am aware that my employer offers a
worksite health program as a benefit to
employees.
I am aware of health and wellness
opportunities at my worksite such as health
screenings and onsite health coaching.
I am well informed about the worksite health
opportunities /offerings available to me
through my employer's worksite health
program.
The programs offered address my concerns
for health and wellness.
The programs do not adequately cover the
areas of health that interest me.
The healthy worksite programs offered to me
are appropriate.
I would like to be offered one or more
different programs than those already being
offered.
The Health Assessment and Health Screening
results and reports provided me with
valuable information about my health.
The health education materials provided to
me gave me a better understanding of how
my lifestyle choices impact my overall health.
My health coach was available and accessible
to me for support.
My coach was supportive and knowledgeable
in the health issues that concern me.
The health coach was available to meet with
me during my work hours.
The surveys I was asked to complete had an
appropriate number of questions.

2

3

4
5
6
7

8

9

10
11
12
13

2

Agree

Neutral

Disagree

Strongly Does
disagree not
apply

Q#

Healthy Worksite Program Quarterly
Survey:

14

I am supportive of changes in policies as a
result of my employers healthy worksite
program.
I am supportive of environmental changes
that create a safe and healthy culture at my
worksite.
I would recommend this worksite health
program to others.
My employer's worksite health program adds
value to my job.
Overall, my employer's worksite health
program had a positive impact on my health.

15

16
17
18

19.1

Strongly
agree

Neutral

Disagree

Strongly Does
disagree not
apply

How useful are the health education materials (newsletters, booklets, handouts) I receive in making healthy
lifestyle changes.
Not at all
Useful

19.2

Agree

Not very
Useful

Somewhat
Useful

Very Useful

Does
not
apply

Tobacco Cessation
Nutrition / Weight Management
Stress Management
Diabetes Awareness and Management
Cholesterol Awareness and Management
Hypertension Awareness and Management
Physical Activity
How informative are the health education materials (newsletters, booklets, handouts) I receive in making
healthy lifestyle changes.
Not at all
Informative

Tobacco Cessation
Nutrition / Weight Management
Stress Management
Diabetes Awareness and Management
Cholesterol Awareness and Management
Hypertension Awareness and Management
Physical Activity

3

Not very
informative

Somewhat
informative

Very
Informative

Does
not
apply

Q#

Healthy Worksite Program Quarterly Survey:

20

Considering your interaction with your Health Coach, how satisfied were you with:
Very
Satisfied

20.1

Somewhat
Satisfied

Somewhat
Dissatisfied

Very
Dissatisfied

Not
Applicable

20.3

The coach's knowledge of your condition
and needs
The length of time provided to you during
your coaching session
The frequency of the coaching sessions

20.4

The professional manner of the coach

20.5

The ability of the coach to motivate you
make lifestyle changes
If you participated in group classes associated with your employer's worksite health program, how satisfied
were you with:

20.2

21

Very
Satisfied

21.1

The times the classes were available

21.2

Your ability to attend classes during your
work day
The frequency of the classes

21.3
21.4
21.5

22

Somewhat
Satisfied

Somewhat
Dissatisfied

Very
Dissatisfied

Not
Applicable

Very
Dissatisfied

Not
Applicable

The topics of the classes offered at your
worksite
The ability of the classes to help you make
lifestyle changes
Overall, how satisfied are you with your employer's worksite health program?
Very
Satisfied

Thank You!

4

Somewhat
Satisfied

Somewhat
Dissatisfied