Health Screening Consent / Contact Form

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

CDC National Healthy Worksite Program (NHWP)
Employee Health 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).
Introduction
This survey asks about your current health status, health behaviors, readiness to change your health
behaviors, your needs and interests related to worksite health and safety, and questions about how your
health may impact your work. Our task is to provide the Centers for Disease Control and Prevention (CDC)
with an evaluation that will further CDC’s understanding of how a worksite health program can 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.
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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 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.

Q#

Question

Response(s)

Demographics
1

Date of Birth

mm/dd/yyyy

2

Gender

Male
Female

3

Are you Hispanic or Latino?

Yes
No
Don’t Know / Not Sure

4

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):

5

Marital Status

Married
Divorced
Widowed
Separated
Never married
Member of unmarried couple

6

What is the highest grade or year of school you
completed?

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)
2

Q#

Question

Response(s)

Health Status
1

Would you say that in general your health is--?

Excellent
Very good
Good
Fair
Poor
Don’t know/Not sure

2

Have you ever been told by a doctor, nurse or
other health professional that you have any of
the following disorders (check all that apply):

Heart disease (heart attack, angina, bypass)
Atrial fibrillation or flutter
Congestive heart failure
Heart valve disease or murmur
Other vascular disease (PAD, PVD, aneurysm)
High blood pressure
Borderline hypertension or pre-hypertension
High blood cholesterol
Diabetes
Elevated blood sugar, borderline diabetes, gestational
diabetes or pre-diabetes
Chronic obstructive pulmonary disease (COPD),
emphysema or chronic bronchitis
Asthma
Arthritis, rheumatoid arthritis, gout, lupus or
fibromyalgia
Carpal tunnel syndrome
Chronic or recurrent low back pain
A depressive disorder (including depression, major
depression, dysthymia or minor depression)

3

4

Are you currently taking medicine for any of the
following conditions?

High blood pressure

Do you take an aspirin daily?

Yes

Asthma
High blood cholesterol
Arthritis
Diabetes
Low back pain

No

3

Q#

Question

Response(s)

Health Status
5
In the past three months, have you had muscle,
skeletal or joint pain, achiness or stiffness in any
of the following areas every day for a week or
more?

Neck or shoulders
Low back
Elbow, wrist or hand
Hip, knee, ankle or foot

6

If yes to question 5, how often does this pain,
aching or stiffness affect you or your activities?

Rarely
Monthly
Weekly
Daily
Never

7

Are you pregnant or considering becoming
pregnant within the next year? (Women only)

Yes
No
Don’t know/Not sure
Does not apply

4

Q#

Question

Response(s)

Preventive Services
1
About how long has it been since you last visited a doctor
for a routine checkup?(A routine checkup is a general
physical exam, not an exam for a specific injury, illness or
condition).

2

Within past year (anytime less than 12
months ago)
Within past 2 years (1 year but less than 2
years ago)
Within past 5 years (2 years but less than 5
years ago)
5 or more years ago
Don’t know/Not sure
Never

The next set of questions asks about preventive services you may have received and when you had them
last?
Blood pressure check
Within past year (anytime less than 12
months ago)
More than 12 months ago
Don’t know/Not sure
Never

3

Cholesterol test

Within past year (anytime less than 12
months ago)
Within past 2 years (1 year but less than 2
years ago)
Within past 5 years (2 years but less than 5
years ago)
5 or more years ago
Don’t know/Not sure
Never

4

Have you had a test for high blood sugar or diabetes
within the past three years?

Yes

Sigmoidoscopy and colonoscopy are exams in which a
tube is inserted in the rectum to view the colon for signs
of cancer or other health problems. Have you ever had
either of these exams?

Yes

5a

5

No
Don’t know/Not sure

No [Skip to Question #6]
Don’t know/Not sure

Q#

Question

Response(s)

Preventive Services
5b

For a SIGMOIDOSCOPY, a flexible tube is inserted into the
rectum to look for problems.
A COLONOSCOPY is similar, but uses a longer tube, and
you are usually given medication through a needle in your
arm to make you sleepy and told to have someone else
drive you home after the test. Was your MOST RECENT
exam a sigmoidoscopy or a colonoscopy?

Sigmoidoscopy

5c

How long has it been since you had your last
sigmoidoscopy or colonoscopy?

Within past year (anytime less than 12
months ago)
Within past 2 years (1 year but less than 2
years ago)
Within past 3 years (2 years but less than 5
years ago)
Within past 5 years (3 years but less than 5
years ago)
Within past 10 years (5 years but less than
10 years ago)
10 or more years ago
Don’t know/Not sure

6

During the past 12 months, have you had either a seasonal Yes
flu shot or a seasonal flu vaccine that was sprayed in your No
nose
Don’t know/Not sure

7a

A mammogram is an x-ray of each breast to look for
breast cancer. Have you ever had a mammogram?

Yes
No [Skip to Question #8a]
Don’t know/Not sure

7b

How long has it been since you had your last
mammogram?

Within past year (anytime less than 12
months ago)
Within past 2 years (1 year but less than 2
years ago)
Within past 3 years (2 years but less than 5
years ago)
Within past 5 years (3 years but less than 5
years ago)
5 or more years ago
Don’t know/Not sure
Never

6

Colonoscopy

Don’t know/Not sure

Q#
Question
Preventive Services
8a
A Pap test is a test for cancer of the cervix. Have you ever
had a Pap test? (women only)

Response(s)

8b

Within past year (anytime less than 12
months ago)
Within past 2 years (1 year but less than 2
years ago)
Within past 3 years (2 years but less than 5
years ago)
Within past 5 years (3 years but less than 5
years ago)
5 or more years ago
Don’t know/Not sure
Never

How long has it been since you had your last Pap test?
(women only)

7

Yes
No [Skip to Lifestyle Section]
Don’t know/Not sure

Q#

Question

Response(s)

Lifestyle
1
Have you smoked at least 100 cigarettes in your
entire life?

Yes
No [Skip to Question #2]
Don’t know/Not sure

1a

Do you now smoke cigarettes every day, some
days or not at all?

Every day [Skip to Question #1b]
Some days Skip to Question #1b]
Not at all [Skip to Question #1c]
Don’t know/Not sure

1b

During the past 12 months, have you stopped
smoking for one day or longer because you were
trying to quit smoking?

Yes [Skip to Question #2]

How long has it been since you last smoked a
cigarette, even one or two puffs?

Within the past month (less than 1 month ago)

Do you currently use chewing tobacco, snuff, or
snus every day, some days or not at all? (snus
rhymes with goose)

Every day

During the past month, other than your regular
job, did you participate in any physical activities
or exercises such as running, calisthenics, golf,
gardening or walking for exercise?

Yes

How many times did you take part in this activity
during the past month?

(number)/month
Don’t know/Not sure

1c

2

3

4

No [Skip to Question #2]
Don’t know/Not sure [Skip to Question #2]

Within the past 3 months (1 month but less than
three months ago)
Within the past 6 months (3 months but less than 6
months ago)
Within past year (6 months but less than 1 year
ago)
Within past 5 years (1 year but less than 5 years
ago)
Within past 10 years (5 years but less than 10 years
ago)
10 years or more
Don’t know/Not sure

8

Some days
Not at all
Don’t know/Not sure

No [Skip to Question #7]
Don’t know/Not sure

Q#
Question
Lifestyle
5
When you took part in this activity, for how many
minutes did you usually keep at it?

Response(s)

6

When you took part in these activities, how
intense was your exercise session?

Low (can sing a song)

7

How often do you use seats belts when you drive
or ride in a car? Would you say…?

Always
Nearly always
Sometimes
Seldom
Never
Don’t know/Not sure

8a

During the past 30 days, how many days per
week or per month did you have at least one
drink of any alcoholic beverage such as beer,
wine, a malt beverage or liquor?

(number) days per week
(number) days in past 30 days
No drinks in past 30 days
Don‘t know / Not sure

8b

One drink is equivalent to a 12-ounce beer, a 5ounce glass of wine or a drink with one shot of
liquor. During the past 30 days, on the days when
you drank, about how many drinks did you drink
on average?

(number) of drinks

(number) minutes
Don’t know/Not sure

Moderate (can carry on a conversation)
High (can only say short sentences)
Very high (winded/single words only)

Not sure/Don’t know

9

During the past 30 days, how often did you eat the following foods per week?

9a

Fatty foods (whole milk, butter, meat, eggs,
cheese, fried foods, chips, ice cream…)

(number) /week

Fruits and vegetables

(number) /week

9b

Not sure/Don’t know

Not sure/Don’t know
9c

9d

Whole grain foods (whole-wheat grains or pasta,
oatmeal…)

(number) /week

Sugary/sweetened foods (cookies, cakes,
sweetened carbonated drinks, chocolate milk…)

(number) /week

9

Not sure/Don’t know

Don’t know/Not sure

Q#

Question

Response(s)

Mental Wellbeing
1
Over the last 2 weeks, how many days have you
had trouble falling asleep OR staying asleep OR
sleeping too much?

2

(number) / 1-14 days
None
Don’t know/Not sure

How often do you get enough restful sleep to
function well in your job and personal life?

Always

How often do you experience stress at work that
exceeds your ability to cope?

Always

4

How often do you experience stress at home that
exceeds your ability to cope?

Always
Most of the time
Sometimes
Rarely
Never
Don’t know/Not sure

5

How often do you get the emotional and social
support you need?

Always

Over the last 2 weeks, how many days have you
felt down, depressed or hopeless?

(number) / 01–14 days

Over the last 2 weeks, how many days have you
had little interest or pleasure in doing things?

(number) / 01–14 days

3

6

7

Most of the time
Sometimes
Rarely
Never
Don’t know/Not sure

10

Most of the time
Sometimes
Rarely
Never
Don’t know/Not sure

Most of the time
Sometimes
Rarely
Never
Don’t know/Not sure

None
Don’t know/Not sure

None
Don’t know/Not sure

Q#
Question
Mental Wellbeing
8
Do you ever think of hurting yourself?

Response(s)
Yes
No
Don’t know/Not sure

9

10

11

Q#

Now thinking about your physical health, which
includes physical illness and injury, for how many
days during the past 4 weeks was your physical
health not good?
Now thinking about your mental health, which
includes stress, depression and problems with
emotions, for how many days during the past 4
weeks was your mental health not good?

During the past 4 weeks, for about how many
days did your poor physical or mental health
keep you doing your usual activities such as selfcare, work, or recreation?

Question

Readiness to Change
1
Which of the
following
best
describes you
regarding
each of these
activities:

1a
1b
1c
1d
1e
1f
1g

(Number) of days

(Number) of days

(Number) of days

Response(s)
I am
satisfied
with the
way I am
now and
have no
desire to
change

I have
considered
making
healthier
choices

I have
seriously
considered
making
healthier
choices and I
am ready to
make a
change

Healthy
eating
Weight loss
Physical
activity
Tobacco use
Stress
reduction
Sleep
Alcohol use

11

I have started
making
healthier
choices

I have already
made changes for
a healthier lifestyle
and I am trying to
maintain them

Not sure
/ Don't
know

Q#

Question

Response(s)

Wellness Opportunities
1

1a
1b
1c
1d
1e
1f
1g
1h
1i
1j
1k
1l
1m
1n
1o
1p
1q

Which of the following health improvement
activities would you be interested in, if
available?
Nutrition/healthy eating
Weight management
Onsite fitness/physical activity opportunities
Walking group
Cholesterol reduction
Blood pressure reduction
Diabetes awareness and management
Men's health issues
Reducing risk of heart disease or stroke
Pre-pregnancy planning
Women's health issues
Back/neck pain management
Anxiety/depression awareness and
management
How to quit tobacco
Managing stress
Medical self-care
Ergonomics (work station or computer setup, proper lifting, etc)

1r
1s
1t

Personal financial management
Allergy and asthma management
Safe sex

2

We will offer 10-15 minute individual health
coaching sessions on a variety of wellness
topics. If you attended, when would it be
best for you?

Yes

No

Immediately before my workday begins
During my break(s)
Immediately after my workday ends
During my workday

3

Not sure / Don't know

How much time during your workday are you
able to dedicate to worksite wellness
activities?

Less than 10 minutes
10-20 minutes
21-30 minutes
31-40 minutes
41-50 minutes
51-60 minutes

12

Q#

Question

Response(s)

Work Related Health History
To what extent do you agree with the following statements?
Strongly
Agree
1
2

3
4

5

6

7

8

9

Agree

After work I have enough
energy for leisure activities.
More and more often, I talk
about my work in a negative
way.
At work, I often feel emotionally
drained.
In the past 4 weeks, I had a hard
time doing my work because of
my health.
In the past 4 weeks, my health
kept me from concentrating on
my work.
In the past 4 weeks, how many
times did you miss part or all of
a workday for any reason?
In the past 4 weeks, how many
times did you miss a half day of
work because of problems with
your physical or mental health?
In the past 4 weeks, how many
times did you miss a full day of
work because of problems with
your physical or mental health?
In the past 12 months, how
many times have you been
injured on the job?

(Number) / times

(Number) / times

(Number) / times

(Number) /times

13

Neutral

Disagree

Strongly
Disagree