Employee Health Assessment

Form Approved

OMB No. 0920-XXXX

Exp. Date: XX-XX-XXXX

CDC National Healthy Worksite Program (NHWP)

Employee Health Assessment (CAPTURE)

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.

• 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 customized solutions to building comprehensive healthy worksite programs. They are helping CDC implement the National Healthy Worksite (NHW) program.

• You were asked to voluntarily complete this survey because your worksite is participating in the 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 survey 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.

The Employee Health Assessment (CAPTURE) tool has modified Question #43 from the Brown University Rapid Eating and Activity Assessment for Patients (REAP) tool and received permission to use it in the CDC National Healthy Worksite Program (NHWP).

Permission to use, copy, and distribute the REAP and REAP provider key for an educational purpose (other than its incorporation into a commercial product) is hereby granted without fee, provided that the below copyright notice appear in all copies and that both that copyright notice and this permission notice appear in the materials, and that the name of Brown University not be used in advertising or publicity pertaining to distribution of the materials without specific, written prior permission. Any adaptation or modification of the REAP tools must receive prior approval from Brown University.

Copyright 2005, Institute for Community Health Promotion, Brown University, Providence, RI. All Rights Reserved.

BROWN UNIVERSITY DISCLAIMS ALL WARRANTIES WITH REGARD TO THESE MATERIALS, INCLUDING ALL IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR ANY PARTICULAR PURPOSE. IN NO EVENT SHALL BROWN UNIVERSITY BE LIABLE FOR ANY SPECIAL, INDIRECT OR CONSEQUENTIAL DAMAGES OR ANY DAMAGES WHATSOEVER RESULTING FROM LOSS OF USE, DATA OR PROFITS, WHETHER IN AN ACTION OF CONTRACT, NEGLIGENCE OR OTHER TORTIOUS ACTION, ARISING OUT OF OR IN CONNECTION WITH THE USE OR PERFORMANCE OF THESE MATERIALS.

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.

Participant ID: ______________________ Employer Code: ____________

Q#	Question	Response(s)
Demographics
1	Date of Birth	mm/dd/yyyy
2	Gender (Source: BRFSS)	Male
		Female
3	Are you Hispanic or Latino? (Source: BRFSS)	Yes
		No
4	What is your race? Do you consider yourself… (Select one or more.)	White
		Black or African American
		Asian
		Native Hawaiian or Other Pacific Islander
		American Indian or Alaska Native
5	Marital Status (Source: BRFSS)	Married
		Divorced
		Widowed
		Separated
		Never married
		Member of unmarried couple
6	What is the highest grade or year of school you completed? (Source: BRFSS)	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)
Q#	Question	Response(s)
Health Status
7	Would you say that in general your health is--? (Source: BRFSS)		Excellent
			Very good
			Good
			Fair
			Poor
			Don’t know/Not sure
8	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)
9	Are you currently taking medicine for any of the following conditions?		High blood pressure
			Asthma
			High blood cholesterol
			Arthritis
			Diabetes
			Low back pain
10	Do you take an aspirin daily or every other day? (Source: BRFSS)		Yes
			No

Q#	Question	Response(s)
Health Status
11	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
12	If yes to question 11, how often does this pain, aching or stiffness affect you or your activities?	Rarely
		Monthly
		Weekly
		Daily
		Never
13	Are you pregnant or considering becoming pregnant within the next year? (Women only)	Yes
		No
		Don’t know/Not sure

Q#	Question	Response(s)
Preventive Services
14	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).	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.
15	Blood pressure check	Within past year (anytime less than 12 months ago)
		More than 12 months ago
		Don’t know/Not sure
		Never
16	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
17	Have you had a test for high blood sugar or diabetes within the past three years?	Yes
		No
		Don’t know/Not sure
18	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? (Source: BRFSS)	Yes
		No [Skip to Question #21]
		Don’t know/Not sure

Q#	Question	Response(s)
Preventive Services
19	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? (Source: BRFSS)	Sigmoidoscopy
		Colonoscopy
		Don’t know/Not sure
20	How long has it been since you had your last sigmoidoscopy or colonoscopy? (Source: BRFSS)	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
21	During the past 12 months, have you had either a seasonal flu shot or a seasonal flu vaccine that was sprayed in your nose? (Source: BRFSS)	Yes
		No
		Don’t know/Not sure
22	A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram? (Source: BRFSS)	Yes
		No [Skip to Question #24]
		Don’t know/Not sure
23	How long has it been since you had your last mammogram? (Source: BRFSS)	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

Q#	Question	Response(s)
Preventive Services
24	A Pap test is a test for cancer of the cervix. Have you ever had a Pap test? (women only) (Source: BRFSS)	Yes
		No [Skip to Question #26]
		Don’t know/Not sure
25	How long has it been since you had your last Pap test? (women only) (Source: BRFSS)	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

Q#	Question	Response(s)
Lifestyle
26	Have you smoked at least 100 cigarettes in your entire life? (Source: BRFSS)	Yes
		No [Skip to Question #30]
		Don’t know/Not sure
27	Do you now smoke cigarettes every day, some days or not at all? (Source: BRFSS)	Every day
		Some days
		Not at all [Skip to Question #29]
28	During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking? (Source: BRFSS)	Yes [Skip to Question #30]
		No [Skip to Question #30]
		Don’t know/Not sure [Skip to Question #30]
29	How long has it been since you last smoked a cigarette, even one or two puffs? (Source: BRFSS)	Within the past month (less than 1 month ago)
		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
30	Do you currently use chewing tobacco, snuff, or snus every day, some days or not at all? (snus rhymes with goose) (Source: BRFSS)	Every day
		Some days
		Not at all
31	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? (Source: BRFSS)	Yes
		No [Skip to Question #38]
		Don’t know/Not sure
Q#	Question	Response(s)
Lifestyle
Consider what type of physical activity or exercise you spent the most time doing during the past month (See Appendix A for examples).
32	How many times did you take part in this activity during the past month? (Source: BRFSS)	(number)/month
		Don’t know/Not sure

33	And when you took part in this activity, for how many minutes did you usually keep at it? (Source: BRFSS)		(number) minutes
			Don’t know/Not sure
34	When you took part in these activities, how intense was your exercise session? (Source: BRFSS)		Low (can sing a song)
			Moderate (can carry on a conversation)
			High (can only say short sentences)
			Very high (winded/single words only)
Now consider what other type of physical activity gave you the NEXT MOST exercise during the past month (Skip to question #38 if no additional physical activity)
35	How many times did you take part in this activity during the past month? (Source: BRFSS)		(number)/month
			Don’t know/Not sure
36	And when you took part in this activity, for how many minutes did you usually keep at it? (Source: BRFSS)		(number) minutes
			Don’t know/Not sure
37	When you took part in these activities, how intense was your exercise session? (Source: BRFSS)		Low (can sing a song)
			Moderate (can carry on a conversation)
			High (can only say short sentences)
			Very high (winded/single words only)
38	How often do you use seats belts when you drive or ride in a car? Would you say…? (Source: BRFSS)		Always
			Nearly always
			Sometimes
			Seldom
			Never
			Don’t know/Not sure
39	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? (Source: BRFSS)		(number) days per week or (number) days in past 30 days
			No drinks in past 30 days
			Don‘t know / Not sure
Q#	Question			Response(s)
Lifestyle
40	One drink is equivalent to a 12-ounce beer, a 5-ounce 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? NOTE: a 40 ounce beer would count as 3 drinks, or a cocktail with 2 shots would count as 2 drinks. (Source: BRFSS)		(number) of drinks
			Don’t know / Not Sure
41	Considering all types of alcoholic beverages, how many times during the past 30 days did you have 5 (men) or 4 (women) or more drinks on an occasion? (Source: BRFSS)		(number) of times
			None
			Don’t know/Not sure
42	During the past 30 days, what is the largest number of drinks you had on any occasion? (Source: BRFSS)		(number) of drinks
			Don’t know/Not Sure
43	During the past 30 days, how many times per week did you eat fried foods such as fried chicken, fried fish, or French fries?1-3 (Source: REAP. Copyright 2005, Institute for Community Health Promotion, Brown University, Providence, RI. All Rights Reserved).		(number) /week
			Don’t know/Not Sure
44	During the past 30 days, not counting juice, how many times per week did you eat fruit? Count fresh, frozen, or canned fruit. (Source: BRFSS)		(number) /week
			Don’t know/Not Sure
45	During the past 30 days, how many times per week did you eat vegetables not including lettuce salads, potatoes, cooked dried bean (Include any form of the vegetable – raw, cooked, canned, or frozen)? EXAMPLES include tomatoes, green beans, carrots, corn, cabbage, bean sprouts, collard greens, and broccoli (Source: NHANES)		(number) /week
			Don’t know/Not Sure
46	During the past 30 days, how many times per week did you eat whole grain foods (whole-wheat grains or pasta, oatmeal)? (Source: NHANES)		(number) /week
			Don’t know/Not sure
47		During the past 30 days, how many times per week did you drink regular soda or pop that contains sugar? Do not include diet soda or diet pop. (Source: BRFSS)		(number) /week
				Don’t know/Not sure
Q#	Question			Response(s)
Mental Wellbeing
48		Over the last 2 weeks, how many days have you had trouble falling asleep OR staying asleep OR sleeping too much? (Source: BRFSS)		(number) / 1-14 days
				None
				Don’t know/Not sure
49		How often do you get enough restful sleep to function well in your job and personal life?		Always
				Most of the time
				Sometimes
				Rarely
				Never
				Don’t know/Not sure
50		How often do you experience stress at WORK that exceeds your ability to cope?		Always
				Most of the time
				Sometimes
				Rarely
				Never
				Don’t know/Not sure
51		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
52		How often do you get the emotional and social support you need? (Source: BRFSS)		Always
				Most of the time
				Sometimes
				Rarely
				Never
				Don’t know/Not sure
53		Over the last 2 weeks, how many days have you felt down, depressed or hopeless? (Source: BRFSS)		(number) / 01–14 days
				None
				Don’t know/Not sure
54		Over the last 2 weeks, how many days have you had little interest or pleasure in doing things? (Source: BRFSS)		(number) / 01–14 days
				None
				Don’t know/Not sure

Q#	Question	Response(s)
Mental Wellbeing
55	Do you ever think of hurting yourself?	Yes
		No
		Don’t know/Not sure
56	Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good? (Source: BRFSS)	(Number) of days
57	Now thinking about your mental health, which includes stress, depression and problems with emotions, for how many days during the past 30 days was your mental health not good? (Source: BRFSS)	(Number) of days
58	During the past 30 days, for about how many days did your poor physical or mental health keep you from doing your usual activities such as self-care, work, or recreation? (Source: BRFSS)	(Number) of days

Q#	Question	Response(s)
Readiness to Change
Which of the following best describes you regarding each of these activities?
		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	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
59	Healthy eating
60	Weight loss
61	Physical activity
62	Tobacco use
63	Stress reduction
64	Sleep
65	Alcohol use

Q#	Question	Response(s)
Wellness Opportunities
Which of the following health topics would you like information on, if available?
		Yes	No
66	Nutrition/healthy eating
67	Weight management
68	Onsite fitness/physical activity opportunities
69	Walking group
70	Cholesterol reduction
71	Blood pressure reduction
72	Diabetes awareness and management
73	Men's health issues
74	Reducing risk of heart disease or stroke
75	Pre-pregnancy planning
76	Women's health issues
77	Back/neck pain management
78	Anxiety/depression awareness and management
79	How to quit tobacco
80	Managing stress
81	Medical self-care
82	Ergonomics (work station or computer set-up, proper lifting, etc.)
83	Personal financial management
84	Allergy and asthma management
85	Safe sex
86	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?	Immediately before my workday begins
		During my break(s)
		Immediately after my workday ends
		During my workday
87	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
		Don’t know/Not sure

Q#	Question	Response(s)
Work Related Health History
To what extent do you agree with the following statements?
			Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
88	After work I have enough energy for leisure activities.
89	More and more often, I talk about my work in a negative way.
90	At work, I often feel emotionally drained.
91	In the past 30 days, I had a hard time doing my work because of my health.
92	In the past 30 days, my health kept me from concentrating on my work.
93	In the past 30 days, how many times did you miss part or all of a workday for any reason?				(Number) / times
94	In the past 30 days, how many times did you miss a half day of work because of problems with your physical or mental health?				(Number) / times
95	In the past 30 days, how many times did you miss a full day of work because of problems with your physical or mental health?				(Number) / times
96	In the past 12 months, how many times have you been injured on the job?				(Number) /times

References:

1. Segal-Isaacson CJ, Wylie-Rosett J, Gans KM. Validation of a short dietary assessment questionnaire: the Rapid Eating and Activity Assessment for Participants short version (REAP-S). Diabetes Educ. 2004 Sep-Oct;30(5):774, 776, 778 passim. PubMed PMID: 15510530.

2. Gans KM, Risica PM, Wylie-Rosett J, Ross EM, Strolla LO, McMurray J, Eaton CB. Development and evaluation of the nutrition component of the Rapid Eating and Activity Assessment for Patients (REAP): a new tool for primary care providers. J Nutr Educ Behav. 2006 Sep-Oct;38(5):286-92. PubMed PMID: 16966049.

3. Gans KM, Ross E, Barner CW, Wylie-Rosett J, McMurray J, Eaton C. REAP and WAVE: new tools to rapidly assess/discuss nutrition with patients. J Nutr. 2003 Feb;133(2):556S-62S. Review. PubMed PMID: 12566502.

APPENDIX A

Activity List for Common Leisure Activities (To be used for Physical Activity Questions as supplemental handout or FAQ sheet)

1 Active Gaming Devices (Wii Fit, Dance Dance revolution)

2 Aerobics video or class

3 Backpacking

4 Badminton

5 Basketball

6 Bicycling machine exercise

7 Bicycling

8 Boating (Canoeing, rowing, kayaking, sailing for pleasure or camping)

9 Bowling

10 Boxing

11 Calisthenics

12 Canoeing/rowing in competition

13 Carpentry

14 Dancing-ballet, ballroom, Latin, hip hop, etc

15 Elliptical/EFX machine exercise

16 Frisbee

17 Gardening (spading, weeding, digging, filling)

18 Golf (with motorized cart)

19 Golf (without motorized cart)

20 Handball

21 Hiking – cross-country

22 Hockey

23 Horseback riding

24 Inline Skating

25 Jogging

26 Lacrosse

27 Mountain climbing

28 Mowing lawn

29 Paddleball

30 Painting/papering house

31 Pilates

32 Racquetball

33 Raking lawn

34 Running

35 Rock Climbing

36 Rope skipping

37 Rowing machine exercise

38 Rugby

39 Scuba diving

40 Skateboarding

41 Skating – ice or roller

42 Sledding, tobogganing

43 Snorkeling

44 Snow blowing

45 Snow shoveling by hand

46 Snow skiing

47 Snowshoeing

48 Soccer

49 Softball/Baseball

50 Squash

51 Stair climbing/Stair master

52 Surfing

53 Swimming

54 Swimming in laps

55 Table tennis

56 Tai Chi

57 Tennis

58 Touch football

59 Volleyball

60 Walking

61 Waterskiing

62 Weight lifting

63 Wrestling

The Employee Health Assessment (CAPTURE) tool has modified Question #43 from the Brown University Rapid Eating and Activity Assessment for Patients (REAP) tool and received permission to use it in the CDC National Healthy Worksite Program (NHWP).

Permission to use, copy, and distribute the REAP and REAP provider key for an educational purpose (other than its incorporation into a commercial product) is hereby granted without fee, provided that the below copyright notice appear in all copies and that both that copyright notice and this permission notice appear in the materials, and that the name of Brown University not be used in advertising or publicity pertaining to distribution of the materials without specific, written prior permission. Any adaptation or modification of the REAP tools must receive prior approval from Brown University.

Copyright 2005, Institute for Community Health Promotion, Brown University, Providence, RI. All Rights Reserved.

BROWN UNIVERSITY DISCLAIMS ALL WARRANTIES WITH REGARD TO THESE MATERIALS, INCLUDING ALL IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR ANY PARTICULAR PURPOSE. IN NO EVENT SHALL BROWN UNIVERSITY BE LIABLE FOR ANY SPECIAL, INDIRECT OR CONSEQUENTIAL DAMAGES OR ANY DAMAGES WHATSOEVER RESULTING FROM LOSS OF USE, DATA OR PROFITS, WHETHER IN AN ACTION OF CONTRACT, NEGLIGENCE OR OTHER TORTIOUS ACTION, ARISING OUT OF OR IN CONNECTION WITH THE USE OR PERFORMANCE OF THESE MATERIALS.

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