All Employee Survey

Form Approved

OMB No. 0920-XXXX

Exp. Date: XX-XX-XXXX

CDC National Healthy Worksite Program (NHWP)

All Employee Survey (INPUTS™)

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.

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 voluntarily 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 Code:	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 job allows me to make a lot of decisions on my own	Strongly disagree	Disagree	Agree	Strongly agree
3	My job requires working very hard	Strongly disagree	Disagree	Agree	Strongly agree
4	The people I work with take a personal interest in me	Strongly disagree	Disagree	Agree	Strongly agree
5	The people I work with can be relied on when I need help	Strongly disagree	Disagree	Agree	Strongly agree
6	My supervisor is concerned about the welfare of those under him or her	Strongly disagree	Disagree	Agree	Strongly agree
7	My supervisor is helpful in getting the job done	Strongly disagree	Disagree	Agree	Strongly agree
8	My job requires me to be creative	Strongly disagree	Disagree	Agree	Strongly agree

To what extent do you agree with the following statements?
Q#	Question	Response
9	My job requires a high level of skill	Strongly disagree	Disagree	Agree	Strongly agree
10	My job requires me to do repeated lifting, pushing, pulling or bending	Strongly disagree	Disagree	Agree	Strongly agree
11	My job regularly requires me to perform repetitive or forceful hand movements	Strongly disagree	Disagree	Agree	Strongly agree
Please answer the following questions.
Q#	Question	Response
12	How often do things going on at work make you feel tense and irritable at home?	Never	Occasionally	Sometimes	Often	Most of the time
13	How often do things going on at home make you feel tense and irritable on the job?	Never	Occasionally	Sometimes	Often	Most of the time

Please rate the following in a scale of 1-10.
Q#	Question	Response
14	Overall, how safe do you think your workplace is (1 -extremely unsafe to 10- extremely safe)	1 Extremely Unsafe	2	3		4	5		6	7		8	9	10 Extremely Safe
15	Overall, how supportive is your company of your personal health, from (1 - extremely unsupportive to 10 - extremely supportive)?	1 Extremely Unsupportive	2	3		4	5		6	7		8	9	10 Extremely Supportive
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
16		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

To what extent do you agree with the following statements?
Q#	Question	Response
17	If my health gets worse, my coworkers would support my recovery	Strongly disagree	Disagree	Neutral	Agree		Strongly agree
18	My coworkers would support my use of sick days for illness or mental health	Strongly disagree	Disagree	Neutral	Agree		Strongly agree
19	My supervisor encourages healthy behaviors	Strongly disagree	Disagree	Neutral	Agree		Strongly agree
20	My organization encourages me to make suggestions about employee safety, health and well-being	Strongly disagree	Disagree	Neutral	Agree		Strongly agree
21	Overall I would recommend working with this organization to my family and friends.	Strongly disagree	Disagree	Neutral	Agree		Strongly agree
Please answer the following questions?
Q#	Question	Response
22	All in all, how satisfied would you say you are with your job?	Very Satisfied	Satisfied	Dissatisfied		Very Dissatisfied
23	How much time do you spend traveling to and from work each day (roundtrip)?	< 15 minutes	15-30 minutes	30 - 60 minutes	60 - 90 minutes		> 90 minutes
24	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)
25	What is your current marital status (Check One)?
	Married
	Divorced
	Widowed
	Separated
	Never married
	Member of an unmarried couple

Please answer the following questions.
26	What is your level of supervisory responsibility (Check One)?
	No supervisory responsibility
	Team leader
	First line supervisor
	Manager
	Executive
27a	Are you Hispanic or Latino?
	Yes
	No
27b	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
28	Date of Birth	mm/dd/yyyy
29	Gender	Male	Female

Thank You!

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