Workplace Health in America Survey

Workplace Health in America Survey Instrument

Form Approved

OMB No. 0920-xxxx

Exp. Date: xx-xx-xxxx

Workplace Health in America Survey

Public reporting of this collection of information is estimated to average 40 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 current 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).

Respondents/Sources	Method	Content	Timing	Respondents	Time per Respondent
Wellness/ Human Resources Representative	Online or by phone	Presence of health promoting practices and programs Presence of organizational supports (budget, management support) and work-life policies Barriers to programs	Participants may begin the survey immediately after they are contacted by telephone, agree to participate, and receive a login code via email.	8085	0.67 hrs

This is a national survey measuring the extent to which employers of various types have employee health promoting programs and practices in place. Employers will be randomly selected and contacted by phone to identify the most appropriate individual to complete the survey and to invite that person to participate on behalf of the worksite. Participants will have the option of completing the survey online or to complete it on the phone with the assistance of an interviewer.

Introduction

Thank you for agreeing to participate in the Workplace Health in America Survey. This survey asks about employee benefits, programs and practices offered at your worksite. Your responses are important in helping the Centers for Disease Control and Prevention, organizations like the American Heart Association, and other employers understand what is really happening in worksites like yours. The survey results will also be available to you, to help you see how your activities and programs compare with similar employers across the nation.

Informed Consent

Before you get started, we’d like to give you some information about participating.

• This project is funded by the CDC. RTI International is the data collection contractor conducting the survey for CDC. RTI is an independent, nonprofit research institute headquartered in Research Triangle Park, North Carolina.

• We are surveying a nationally representative sample of worksites representing all sizes, industries, and regions. Your worksite was randomly selected as a representative of your size, industry and region.

• Your participation in this survey is voluntary.

• The survey is designed to take about 40 minutes for most worksites.

• All of the answers you provide will be maintained in a secure manner. We will not disclose your responses unless we are compelled by law. Your responses will be combined with responses from other worksites and reported in the aggregate.

• 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 survey.

• If you have any questions, you can contact Laurie Cluff at RTI International. Her phone number is 919-541-6514 and her email is [email protected].

ORGANIZATIONAL CHARACTERISTICS

OC1. What department are you most affiliated with in your worksite?

Human Resources and/or Benefits

Health Promotion/Fitness/Wellness

Safety

Medical

PR/Marketing

Finance

Other ______________________________ (name)

OC2. How many part-time and full-time employees are based at this worksite location? (Please feel free to provide an estimate, even if you are not sure of the exact number.)

(___________ enter total number full and part-time employees here)

OC3. Is your organization…

For profit, public

For profit, private

Non-profit

State or local government

Federal government

Other

Refused

HEALTH INSURANCE

HI1. Does your organization currently offer personal health insurance for your full-time employees?

Yes

No

Don’t know

Refused

[If HI1 is NO, DK, REF to HI 1. Skip to HI2]

HI1.a. In general, do you offer full, partial or no payment of premiums for personal health insurance for full-time employees?

Full

Partial

None

Don’t know

Refused

HI1.b. Over the past 12 months, were full time employees asked to pay a larger proportion, smaller proportion or the same proportion of personal health insurance premiums compared to the previous 12 months (just premiums and not deductibles or co-pays)?

Larger

Smaller

About the same

Don’t know

Refused

HI2. Does your organization offer personal health insurance for your part-time employees?

Yes

No

Don’t know

Refused

HI3. Does your organization offer family coverage with your health insurance?

Yes

No

Don’t know

Refused

HEALTH RISK ASSESSMENTS

HRA1. In the past 12 months, were employees at this worksite location offered a health risk assessment or HRA?

Yes

No

Don’t know

Refused [IF HRA 1 is NO, DK, REF, skip to CP1]

HRA1.a. Who offered the HRA?

The employer

The health insurance plan

A different third party vendor (i.e., not a health insurance provider)

Don’t know

Refused

HRA1.b. Approximately what percentage of employees completed the HRA? (Please feel free to provide an estimate, even if you are not sure of the true percentage.)

1-25%

26-50%

51-75%

76-100%

Don’t know

Refused

HRA1.c. Did employees receive an incentive for completing the HRA?

Yes

No

Don’t know

Refused

HRA1.d. We will ask about other incentives offered later, but we are asking one specific question about the HRA: Did employees receive an incentive if they met certain target health goals specified in the HRA?

Yes

No

Don’t know

Refused

HRA1.e.1. Did employees who completed the HRA receive their results?

Yes

No

Don’t know

Refused

HRA1.e.2. Were employees who completed the HRA provided feedback and education for identified health risks or conditions?

Yes

No

Don’t know

Refused

PROMOTING HEALTH AT WORK

Does your worksite currently offer:	Yes	No	Don’t know	Refused
CP1. Health education programs….which focus on skill development and lifestyle behavior change along with information dissemination and awareness building, preferably tailored to employees’ interests and needs?
CP2. Supportive social and physical environment…..which includes an organization’s expectations regarding healthy behaviors, and implementation of policies that promote health and reduce risk of disease? For example – signage that promotes using the stairs, policies to restrict smoking, or increasing access to healthy foods at work.
CP3. Integration of the health promotion program into your organization’s structure which includes allocating dedicated resources, budget and/or aligning with your business plan?
CP4. Linkage to related programs like employee assistance programs (EAPs) and programs to help employees balance work and family?
CP5. Worksite health screening programs, ideally linked to medical care to ensure follow-up and appropriate treatment as necessary?

HISTORY OF HEALTH PROMOTION

Now we want to ask more detailed information about how HEALTH PROMOTION/WELLNESS PROGRAMS are organized at this worksite location. For the purpose of the next question, think VERY BROADLY about any educational materials, activities, classes, screenings, services, environmental supports, or policies that encourage employees to be healthy.

HP1. Thinking about this worksite location, did your organization offer any type of health promotion/wellness program for employees in the past 12 months?

Yes

No

Don’t know

Refused [If NO --- skip to Work-Life question WL1-7]

HP2. How long has your health promotion/wellness program been in place?

Less than 1 year

1 to 2 years

3 to 5 years

6 to 9 years

10 years or more

Don’t know

Refused

HP3. Is your health promotion/wellness program primarily managed by… (please choose one )

Staff employed by our organization

Staff employed by our health insurance provider

Staff employed by a vendor/some other third party provider (not the health insurance provider)

Don’t know

Refused

HP4. Is there at least one person who is assigned responsibility for the health promotion/wellness program offered at this worksite location?

Yes

No

Don’t know

Refused [If HP4. is NO, DK, REF, skip to HP5.]

HP4.a. How is the assigned person compensated for his/her responsibilities related to employee health promotion/wellness? (please choose one)

Person works full time and primary job responsibilities are related to employee health promotion/wellness.

Person works full or part time and employee health promotion/wellness is part of his/her job responsibilities

Person works full or part-time and volunteers to work on employee health promotion/wellness – he/she has no official paid job responsibilities for employee health/wellness.

Don’t know

Refused

HP4.b. How many total full and part-time employees have some PAID responsibilities to plan, promote, implement and/or champion employee health promotion/wellness at this worksite location?

(___________ enter total number full and part-time PAID employees here, include 0)

Don’t know

Refused

HP4.c. How many total full and part-time employees VOLUNTEER to plan, promote, implement and/or champion employee health promotion/wellness at this worksite location?

(___________ enter total number full and part-time VOLUNTEER employees here, include 0)

Don’t know

Refused

HP5. Does this worksite currently have a committee that addresses employee health promotion/wellness or safety? (Please choose one):

Yes, there is one committee, includes both health promotion/wellness and safety

Yes, there is one committee, includes health promotion/wellness but NOT safety

Yes, there is one committee, includes safety but NOT health promotion/wellness

Yes, there are two separate committees, one for health promotion/wellness and one for safety

NO, we have no committee addressing health promotion or safety --- [SKIP to HP6]

Don’t know

Refused [IF NO, DK, REF, Skip to HP6.]

HP5.a. To what extent does this committee adequately represent a wide variety of workers (e.g. employees from different departments, shifts, and a wide array of health interests?)

1= not representative at all

2=somewhat representative

3=mostly representative

4=entirely representative

Don’t know

Refused

HP5.b. How effective is the committee in promoting safety and health for employees at this worksite location?

1=not effective at all

2=somewhat effective

3=effective

4=extremely effective

Don’t know

Refused

HP6. Does this organization include references to improving or maintaining employee health in the business objectives or organizational mission statement?

Yes

No

Don’t know

Refused

HP7. Thinking about your health promotion/wellness program at this worksite location overall, would you say it…	Yes	No	Don’t know	Refused
HP7.a. Has senior leadership visibly committed to employee health and safe work environments?
HP7.b. Has middle management visibly committed to employee health and safe work environments?
HP7.c. Has a champion(s) who is a strong advocate for the health promotion program?
HP7.d. Has an annual employee health promotion plan? [If HP7.d. is NO, DK, REF, skip to HP7.e.]
HP7.d.1 Does the plan include specific measurable goals and objectives to reach?
HP7.d.2 Does the plan include communication strategies that promote and market the program to employees to ensure high visibility of the program?
HP7.d.3 Does the plan include clear responsibility for who will implement each component of the plan?
HP7.e. Uses data to help decision-makers decide what to offer? [IF HP7.e. is NO, DK, REF, skip to HP7.f]
HP7.e.1. Do you use any type of organizational level assessment tool to benchmark changes, plan and/or evaluate health-related organizational level changes that you may make over time?   (for example, CDC Worksite Health ScoreCard, HERO, Work Healthy America Tool)
What types of data are used to make plans?
HP7.e.2. Characteristics of employees (e.g. age or gender)?
HP7.e.3. Employee health interests?
HP7.e.4. Employee health behavior risks (# of smokers, # of overweight, etc.)?
HP7.e.5. Cost of health care or health care claims paid?
HP7.e.6. Some other type of data (Specify_____________________)
HP7.f. Uses data to evaluate program success? [IF HP7.f is NO, DK, REF, skip to HP7.h.]
HP7.g. What types of data are used to evaluate program success?
HP7.g.1. Employee participation?
HP7.g.2. Employee feedback about the program?
HP7.g.3. Employee morale or job satisfaction?
HP7.g.4. Changes in employee health risk behaviors?
HP7.g.5. Changes in employee disease rates or conditions?
HP7.g.6. Costs for employee health care claims?
HP7.g.7. Number or amount of worker compensation claims?
HP7.g.8. Absenteeism?
HP7.g.9. Employee productivity or presenteeism?
HP7.g.10. Employee turnover?
HP7.g.11. Return on investment?
HP7.h. Has an annual budget to provide employee health/wellness programs independent of the programs/services offered as part of your health insurance plan? [If HP7.h. is NO, DK, REF, skip to HPR1]

HP7.h.1. How much is available in dollars, annually, to spend on employee health promotion/wellness at this worksite location? [Note: it is fine to include salaries of employees who have responsibility for employee health as part of his/her job responsibility]

Less than $1000

$1001-5000

$5001-10,000

$10,001-15,000

$15,001-20,000

$20,001-$50,000

$50,001 to 100,000

$100,000-500,000

Over $500,000

Don’t know

Refused

[If they did not choose DK or Ref, ask HP7.h.1.a]

HP7.h.1.a. Approximately what percentage of this amount covers staff salaries? 

___%

Don’t know

Refused

HP8. During the next 12 months (compared with the past 12 months), what do you expect that your organization’s financial investment will be in employee health promotion? (please choose one)

We will spend more

We will spend less

We will spend about the same amount

Don’t know

Refused

HEALTH PROMOTION PROGRAMS, HEALTH SCREENINGS, DISEASE MANAGEMENT

Next we will cover health education programs, environmental supports and policies/benefits related to specific health behaviors. Specifically, “programs” refer to any educational opportunity that seeks to improve knowledge, skills and/or change behaviors in ways that promote employee health or prevent disease using any of a variety of methods including print/online materials, contests, classes and/or other activities.

We will take one health behavior at a time and ask a series of questions about programs, then some specific strategies for environmental supports and policies/benefits that employers may offer.

HPR1 Physical Activity/Fitness/Sedentary Behavior

HPR1.1. In the past 12 months, did you offer any programs to address physical activity/fitness/sedentary behavior for your employees?

Yes

No

Don’t know

Refused [If NO, DK, REF, skip to HPR1.2.]

HPR1.1a. What TYPE of physical activity programs have you offered in the past 12 months?

Awareness or Informational (e.g. this includes print or online materials, posters, flyers, brochures, educational materials, one-time presentations)

Skill-building – (e.g. this includes onsite, online classes or offsite classes in the community; one on one coaching; contests or competitions)

Both awareness/information and skill-building

Don’t know

Refused

HPR1.1.b. Who typically offers these programs to employees?

Offered mostly by the employer

Offered mostly by the health plan

Offered mostly by a outsourced vendor, not the health plan

Offered mostly by combined efforts of employer, health plan and/or vendor

Don’t know

Refused

HPR1.1.c. Thinking about all physical activity/fitness/sedentary behavior programs that have been offered or sponsored here in the past 12 months, approximately what percentage of employees from this worksite location participate? (Please feel free to provide an estimate, even if you are not sure of the true percentage.)

1-25%

26-50%

51-75%

More than 75%

Don’t know

Refused

HPR1.2. In the past 12 months, did you offer any of the following specific strategies to help increase physical activity?	Yes	No	Don’t know	Refused
HPR1.2.a. Provide an exercise facility on-site?
HPR1.2.b. Subsidize or discount the cost of onsite and /or offsite exercise facilities?
HPR1.2.c. Provide environmental supports for physical activity or recreation such as walking trails or tracks, maps of measured walking/jogging routes, bicycle racks, shower and changing room, open space for recreation, weight room?
HPR1.2.d. Post signs at elevators, stairwell entrances/exits and other key locations that encourage employees to use the stairs?
HPR1.2.e. Provide organized individual or group physical activity programs for employees (other than use of an exercise facility?) (e.g. walking or stretching , group exercise classes or weight training)
HPR1.2.f. Provide or subsidize physical fitness assessments, follow-up counseling, and exercise recommendations either onsite or through a community exercise facility?
HPR1.2.g. Provide free or subsidized lifestyle self-management programs that include advice on physical activity?
HPR1.2.h. Provide a pedometer or FITBit or other physical activity tracking device for free or discounted rate to employees?
HPR1.2.i. Provide the option of using active work stations? (e.g. standing desk, treadmill desk, height adjustable workstation, pedal devices fitted underneath the desk)
HPR1.2.j. Offer employees paid time to be physically active during work hours, including fitness breaks, walking meetings or other options?
HPR1.2.k. Encourage active transportation to and from work by providing things such as bike parking, shower access, pre-tax contributions for public transportation or providing parallel benefits to those who bike, walk or take transit to work as those who drive?

HPR2 Nutrition/Healthy Eating

HPR2.1. In the past 12 months, did you offer any programs to address nutrition and/or healthy eating for employees?

Yes

No

Don’t know

Refused [If NO, DK, REF, skip to HPR2.2.]

HPR2.1.a. What TYPE of nutrition/healthy eating programs have you offered in the past 12 months?

Awareness or Informational (e.g. this includes print or online materials, posters, flyers, brochures, educational materials, one-time presentations)

Skill-building – (e.g. this includes onsite, online classes or offsite classes in the community; one on one coaching; contests or competitions)

Both awareness/information and skill-building

Don’t know

Refused

HPR2.1.b. Who typically offered these programs to employees?

Offered mostly by the employer

Offered mostly by the health plan

Offered mostly by a outsourced vendor, not the health plan

Offered mostly by combined efforts of employer, health plan and/or vendor

Don’t know

Refused

HPR2.1.c. Thinking about all nutrition/healthy eating programs that have been offered or sponsored here in the past 12 months, approximately what percentage of employees from this worksite location participate?

(Please feel free to provide an estimate, even if you are not sure of the true percentage.)

1-25%

26-50%

51-75%

More than 75%

Don’t know

Refused

HPR2.2. In the past 12 months, did you offer any of the following specific strategies addressing nutrition/health eating?	Yes	No	Don’t know	Refused
HPR2.2a. Provide employees with food preparation and storage facilities such as microwave oven, sink, refrigerator and/or kitchen?
HPR2.2.b. A written policy or formal communication which makes healthier food and beverages available during meetings when food is served?
HPR2.2.c. Offer or promote an onsite or nearby farmers market where fresh fruits and vegetables are sold?
HPR2.2.d. Provide free or subsidized lifestyle self-management programs that include advice or tools on healthy eating?
HPR2.3. Does your worksite location have…
HPR2.3.a. A cafeteria or snack bar onsite?
HPR2.3.b. Vending machines that serve food?
HPR2.3.c. Vending machines that serve beverages?
HPR2.3.d. Food trucks that come to your worksite every day?

[IF YES to one of HPR2.3 a-d, ask HPR2.4.a. – e., otherwise skip to HPR3.1.]

HPR2.4. Does your worksite location…	Yes	No	Don’t know	Refused
HPR2.4.a. Have a written policy or formal communication that makes healthier food and beverage choices available in cafeterias, vending, snack bars or food trucks?
HPR2.4.b. Make most (more than 50%) of the food and beverage choices available in cafeterias/snack bars, vending, catering trucks be healthy food items?
HPR2.4.c. Provide nutritional information (beyond standard info on labels) on sodium, calories, trans-fats, or saturated fats for foods and beverages sold in worksite cafeterias, snack bars, vending or food trucks?
HPR2.4.d. Identify healthier food and beverage choices with signs or symbols?
HPR2.4.e. Subsidize or provide discounts on healthier foods and beverages offered in vending machines, cafeterias, snack bars or food trucks?

HPR3 Obesity/Weight Management

HPR3.1. In the past 12 months, did you offer any programs to address obesity/weight management for employees?

Yes

No

Don’t know

Refused [If NO, DK, REF to HPR3.1. then SKIP to HPR3.2.]

HPR3.1.a. What TYPE of obesity/weight management programs have you offered in the past 12 months?

Awareness or Informational (e.g. this includes print or online materials, posters, flyers, brochures, educational materials, one-time presentations)

Skill-building – (e.g. this includes onsite, online classes or offsite classes in the community; one on one coaching; contests or competitions)

Both awareness/information and skill-building

Don’t know

Refused

HPR3.1.b. Who typically offered these programs to employees?

Offered mostly by the employer

Offered mostly by the health plan

Offered mostly by a outsourced vendor, not the health plan

Offered mostly by combined efforts of employer, health plan and/or vendor

Don’t know

Refused

HPR3.1.c. Thinking about all obesity/weight management programs that have been offered or sponsored here in the past 12 months, approximately what percentage of employees from this worksite location participate? (Please feel free to provide an estimate, even if you are not sure of the true percentage.)

1-25%

26-50%

51-75%

More than 75%

Don’t know

Refused

HPR3.2. In the past 12 months, did you offer any of the following specific strategies for managing weight/obesity?	Yes	No	Don’t know	Refused
HPR3.2.a. Provide free or subsidized body composition measurement, such as height and weight, BMI scores, or body fat assessments (not self-report) followed by directed feedback and/or clinical referral when appropriate?
HPR3.2.b. Provide brochures, videos, posters, pamphlets, newsletters, or other written or online information that address the risks of overweight or obesity?
HPR3.2.c. Provide educational seminars, workshops, or classes on weight management?
HPR3.2.d. Provide free or subsidized one-on-one or group lifestyle counseling for employees on weight management?
HPR3.2.e. Provide free or subsidized lifestyle self-management programs that include advice or tools on weight management

HPR4 Tobacco Use

HPR4.1. In the past 12 months, did you offer any programs to help employees stop using tobacco products?

Yes

No

Don’t know

Refused [If NO, DK, REF to HPR4.1 then SKIP to HPR4.2.]

HPR4.1.a. What TYPE of tobacco use programs have you offered in the past 12 months?

Awareness or Informational (e.g. this includes print or online materials, posters, flyers, brochures, educational materials, one-time presentations)

Skill-building – (e.g. this includes onsite, online classes or offsite classes in the community; one on one coaching; contests or competitions)

Both awareness/information and skill-building

Don’t know

Refused

HPR4.1.b. Who typically offered these programs to employees?

Offered mostly by the employer

Offered mostly by the health plan

Offered mostly by a outsourced vendor, not the health plan

Offered mostly by combined efforts of employer, health plan and/or vendor

Don’t know

Refused

HPR4.1.c. Thinking about all tobacco use programs that have been offered or sponsored here in the past 12 months, approximately what percentage of employees from this worksite location participate? (Please feel free to provide an estimate, even if you are not sure of the true percentage.)

1-25%

26-50%

51-75%

More than 75%

Don’t know

Refused

HPR4.2. In the past 12 months, did you offer any of the following specific strategies for eliminating use of tobacco products or minimizing exposure to secondhand smoke at work?	Yes	No	Don’t know	Refused
HPR4.2.a. Refer tobacco users to a state or other tobacco cessation telephone quit line?
HPR4.2.b. Provide or cover free or subsidized tobacco cessation counseling (including individual, group, and telephone counseling)?
HPR4.2.c. Provide health insurance coverage with no or low out-of-pocket costs for FDA-approved over-the-counter and/or prescription tobacco cessation medications including nicotine replacement?
HPR4.2.d. Inform employees about health insurance coverage or programs that include tobacco cessation medication and counseling?
HPR4.2.e. Help remove barriers to accessing tobacco cessation treatments, such as copayments, requirements for prior authorization, and limitations on the number and duration of treatments?
HPR4.2.f. Display signs (including ‘no smoking’ signs)?
HPR4.2.g. Have a written policy to restrict smoking? [if NO, DK, REF, skip to HPR.5.1.]

HPR4.2.g. In the past 12 months, did you offer any of the following specific strategies for eliminating use of tobacco products or minimizing exposure to secondhand smoke at work?	Yes	No	Don’t know	Refused/ Does not apply
HPR4.2.g.1. Does the written policy ban all tobacco use at your worksite?
HPR4.2.g.2. Does the written policy ban use of smokeless tobacco, e-cigarettes and other tobacco products?
HPR4.2.g.3. Actively enforce a written policy banning tobacco use?
HPR4.2.g.4. Have a policy that does not allow use of tobacco products in company vehicles? (Include option for Does not apply)
HPR4.2.g.5. Prohibit sale of tobacco products on company property (for example, your worksite does not sell tobacco products on company property in vending machines or through on-site vendors)?

HPR4.2.g.6. Which of these best describes your smoking policy for INDOOR PUBLIC OR

COMMON AREAS, such as lobbies, rest rooms, and lunch rooms?

Not allowed in ANY public areas

Allowed in some public areas

Allowed in ALL public areas

Not applicable

Don’t know

Refused

HPR4.2.g.7. Which of these best describes your smoking policy for WORK AREAS?

Not allowed in ANY work areas

Allowed in some work areas

Allowed in ALL work areas

Not applicable

Don’t know

Refused

HP5 Excessive Alcohol Use/Drug Abuse

HPR5.1. In the past 12 months, did you offer any programs to address excessive alcohol use and/or drug abuse?

Yes

No

Don’t know

Refused [If NO, DK, REF to HPR5.1. then SKIP to HPR5.2.]

HPR5.1.a. What TYPE of excessive alcohol use/drug abuse programs have you offered in the past 12 months?

Awareness or Informational (e.g. this includes print or online materials, posters, flyers, brochures, educational materials, one-time presentations)

Skill-building – (e.g. this includes onsite, online classes or offsite classes in the community; one on one coaching; contests or competitions)

Both awareness/information and skill-building

Don’t know

Refused

HPR5.1.b. Who typically offered these programs to employees?

Offered mostly by the employer

Offered mostly by the health plan

Offered mostly by a outsourced vendor, not the health plan

Offered mostly by combined efforts of employer, health plan and/or vendor

Don’t know

Refused

HPR5.1.c. Thinking about all programs to eliminate excessive use of alcohol/drug abuse that have been offered or sponsored here in the past 12 months, approximately what percentage of employees from this worksite location participate? (Please feel free to provide an estimate, even if you are not sure of the true percentage.)

1-25%

26-50%

51-75%

More than 75%

Don’t know

Refused

HPR5.2. In the past 12 months, did you offer any of the following specific strategies for eliminating excessive use of alcohol/drug abuse among employees at work?	Yes	No	Don’t know	Refused
HPR5.2.a. Participate in a community coalition that is addressing excessive alcohol use, drug abuse, or both?
HPR5.2.b. Offer excessive alcohol use or drug abuse support programs?
HPR5.2.c. Do you have a formal, written policy for addressing employee use of alcohol at the worksite/on the job?
HPR5.2.d. Do you have a formal, written policy addressing employee use of drugs at the worksite/on the job?
HPR5.2.e. Do you have a formal, written policy addressing employee use of medical marijuana at the worksite/on the job?

HPR6 Lactation Support

HPR6.1. In the past 12 months, did you offer any lactation support programs for employees?

Yes

No

Don’t know

Refused [If NO, DK, REF to HPR6.1. then SKIP to HPR6.2.]

HPR6.1.a. What TYPE of lactation support programs have you offered in the past 12 months?

Awareness or Informational (e.g. this includes print or online materials, posters, flyers, brochures, educational materials, one-time presentations)

Skill-building – (e.g. this includes onsite, online classes or offsite classes in the community; one on one coaching; contests or competitions)

Both awareness/information and skill-building

Don’t know

Refused

HPR6.1.b. Who typically offered these programs to employees?

Offered mostly by the employer

Offered mostly by the health plan

Offered mostly by a outsourced vendor, not the health plan

Offered mostly by combined efforts of employer, health plan and/or vendor

Don’t know

Refused

HPR6.1.c. Thinking about all support programs for breastfeeding or pregnant employees that have been offered or sponsored here in the past 12 months, approximately what percentage of employees from this worksite location participate? (Please feel free to provide an estimate, even if you are not sure of the true percentage.)

1-25%

26-50%

51-75%

More than 75%

Don’t know

Refused

HPR6.2. In the past 12 months, did you offer any of the following specific strategies to support pregnant or breastfeeding employees at this worksite location?	Yes	No	Don’t know	Refused
HPR6.2.a. Have a written policy on breastfeeding for employees?
HPR6.2.b. Provide a private space (other than a restroom) that may be used by an employee to pump breast milk?
HPR6.2.c. Provide access to a breast pump at the worksite?
HPR6.2.d. Provide flexible times to allow mothers to pump breast milk at this worksite location?
HPR6.2.e. Provide free or subsidized breastfeeding support groups or educational classes?
HPR6.2.f. Offer paid maternity leave, separate from any accrued sick leave, annual leave or vacation time?

HPR7 Musculoskeletal Disorders/Arthritis/Back Pain

HPR7.1. In the past 12 months, did you offer any programs to educate about prevention of musculoskeletal disorders, arthritis or back pain?

Yes

No

Don’t know

Refused [If NO, DK, REF to HPR7.1. then SKIP to HPR7.2.]

HPR7.1.a. What TYPE of musculoskeletal disorder, arthritis, or back pain programs have you offered in the past 12 months?

Awareness or Informational (e.g. this includes print or online materials, posters, flyers, brochures, educational materials, one-time presentations)

Skill-building – (e.g. this includes onsite, online classes or offsite classes in the community; one on one coaching; contests or competitions)

Both awareness/information and skill-building

Don’t know

Refused

HPR7.1.b. Who typically offered these programs to employees?

Offered mostly by the employer

Offered mostly by the health plan

Offered mostly by a outsourced vendor, not the health plan

Offered mostly by combined efforts of employer, health plan and/or vendor

Don’t know

Refused

HPR7.1.c. Thinking about all musculoskeletal disease, arthritis or back pain programs that have been offered or sponsored here in the past 12 months, approximately what percentage of employees from this worksite location participate? (Please feel free to provide an estimate, even if you are not sure of the true percentage.)

1-25%

26-50%

51-75%

More than 75%

Don’t know

Refused

HPR7.2. In the past 12 months, did you offer any of the following specific strategies to prevent musculoskeletal disease, arthritis or back pain?	Yes	No	Don’t know	Refused
HPR7.2.a. Training for managers and workers on identifying or recognizing work conditions that might increase risk of musculoskeletal disease, arthritis, or back pain?
HPR7.2.b. A written injury prevention program?
HPR7.2.c. Intervention strategies for controlling ergonomic hazards with engineering or administrative controls?
HPR7.2.d. Ergonomic assessments and reasonable accommodations?
HPR7.2.e. Educate employees about worker compensation and disability benefits?
HPR7.2.f. Policies to ensure that employees return to work safely and avoid re-injury?

HPR8 Stress Management

HPR8.1. In the past 12 months, did you offer any programs to address stress management for employees?

Yes

No

Don’t know

Refused [If NO, DK, REF to HPR8.1. then SKIP to HPR8.2.]

HPR8.1.a. What TYPE of stress management programs have you offered in the past 12 months?

Awareness or Informational (e.g. this includes print or online materials, posters, flyers, brochures, educational materials, one-time presentations)

Skill-building – (e.g. this includes onsite, online classes or offsite classes in the community; one on one coaching; contests or competitions)

Both awareness/information and skill-building

Don’t know

Refused

HPR8.1.b. Who typically offered these programs to employees?

Offered mostly by the employer

Offered mostly by the health plan

Offered mostly by a outsourced vendor, not the health plan

Offered mostly by combined efforts of employer, health plan and/or vendor

Don’t know

Refused

HPR8.1.c. Thinking about all stress management programs that have been offered or sponsored here in the past 12 months, approximately what percentage of employees from this worksite location participate? (Please feel free to provide an estimate, even if you are not sure of the true percentage.)

1-25%

26-50%

51-75%

More than 75%

Don’t know

Refused

HPR8.2. In the past 12 months, did you offer any of the following specific strategies for stress management?	Yes	No	Don’t know	Refused
HPR8.2.a. Dedicated space that is quiet where employees can engage in relaxation activities, such as meditation, yoga, prayer or naps?
HPR8.2.b. Social events throughout the year? (e.g. worksite sponsors or organizes team building events, company picnics or employee sports teams)
HPR8.2.c. Training for managers on identifying and reducing stress-related issues?  (e.g., training on conducting equitable performance reviews, communication, personnel management, assertiveness, time management, job redesign, or conflict resolution)
HPR8.2.d. Opportunities for employee to participate in organizational decisions (e.g. procedures, scheduling, and workload) that affect job stress?
HPR8.2.e. Safe places and/or opportunities that encourage social connectedness for employees at work (e.g. places that that allow people to interact and build supportive relationships and meaningful connections)?

HPR9 Sleep

HPR9.1. In the past 12 months, did you offer any programs to promote healthy sleep and reduce fatigue for employees?

Yes

No

Don’t know

Refused [If NO, DK, REF to HPR9.1. then SKIP to HPR9.2.]

HPR9.1.a. What TYPE of healthy sleep programs have you offered in the past 12 months?

Awareness or Informational (e.g. this includes print or online materials, posters, flyers, brochures, educational materials, one-time presentations)

Skill-building – (e.g. this includes onsite, online classes or offsite classes in the community; one on one coaching; contests or competitions)

Both awareness/information and skill-building

Don’t know

Refused

HPR9.1.b. Who typically offered these programs to employees?

Offered mostly by the employer

Offered mostly by the health plan

Offered mostly by a outsourced vendor, not the health plan

Offered mostly by combined efforts of employer, health plan and/or vendor

Don’t know

Refused

HPR9.1.c. Thinking about all the healthy sleep programs that have been offered or sponsored here in the past 12 months, approximately what percentage of employees from this worksite location participate? (Please feel free to provide an estimate, even if you are not sure of the true percentage.)

1-25%

26-50%

51-75%

More than 75%

Don’t know

Refused

HPR9.2. In the past 12 months, did you offer any of the following specific strategies to support healthy sleep?	Yes	No	Don’t know	Refused
HPR9.2.a. Training for workers about the importance of getting sufficient sleep for their safety, health and well-being both on and off the job.
HPR9.2.b. Training for workers to help them cope with shift work and long work hours.
HPR9.2.c. Training for managers on the safety and health risks associated with employee fatigue and poor sleep?
HPR9.2.d.Training for managers to improve the organization of work so as to reduce employee risk for poor sleep and fatigue
HPR9.2.e.Improve design of work schedules, including policies for the number of consecutive days or hours allowed to be worked, or the type of shifts in place
HPR9.2.f. Offer breaks during the work shift  or work day

HEALTH SCREENINGS

Now let’s talk about health screening tests that may be offered to employees at this worksite location. Health screenings are offered to employees to help detect health problems to get employees referred for proper treatment.

In the past 12 months, were any of the following screenings made available to your employees?	Screened (Y/N/DK/REF) [If Screened is YES, ask questions in columns b.- d.]	Are high risk employees referred to health professional for treatment? (Y/N/DK/REF)	Is follow-up education provided to those identified as high risk? (Y/N/DK/REF)	Is lifestyle coaching/counseling provided to those identified as high risk? (Y/N/DK/REF)
HS1.1. Blood pressure [If NO to HS1.1.a., skip to HS1.2.]
HS1.1.1. Were blood pressure monitoring devices available with instructions for employees to conduct their own self assessments?
HS1.2. Blood cholesterol
HS1.3. Diabetes or pre-diabetes
HS1.4. Obesity
HS1.5. Breast cancer using mammography
HS1.6. Colorectal cancer using a colonoscopy or a kit to measure blood in the stool
HS1.7. Cervical cancer using a PAP test or test for human papillomavirus (HPV)
HS1.8. Depression
HS1.9. Arthritis or other musculoskeletal problems

HS2.a. Thinking about all of the screenings offered to employees at this worksite, were they usually offered to employees…

Onsite

Offsite

Both

Don’t know

Refused

HS2.b. Thinking about all of the screenings offered to employees at this worksite, who usually covered the cost of health screenings?

Paid by the employer

Paid by the employee

Cost is shared between the employer and employee

Don’t know

Refused

HS2.c. Think about all of the health screenings offered to employees at this worksite. Would you estimate the usual employee participation as:

1-25%

26-50%

51-75%

More than 75%

Don’t know

HS3. During the past 12 months, were flu shots made available to your employees?

Yes, onsite

Yes, offsite

Yes, onsite and offsite

No

Don’t know

Refused

DISEASE OR RISK MANAGEMENT

Disease or risk management information or programs: These programs are offered for employees who already have a particular disease or health condition and can include specific information, education and/or services to better manage the condition. These programs may be offered to employees either through your health plan, a third-party vendor, or directly by the employer.

	Select all that apply			Nothingoffered for this topic	DK/Ref	[If offered ask] Was this offered by your largest health insurance plan? Yes/No/DK/Ref
During the past 12 months, were any disease or risk management information or programs related to the following topics made available to your employees? (please include programs provided by the employer, health plan or third party vendor)	Information, such as brochures, videos, posters, pamphlets, newsletters	Educational seminars, workshops, or classes on preventing and controlling the condition	One-on-one counseling/coaching and follow-up monitoring
DM1.1. Arthritis
DM1.2. Asthma
DM1.3. Back injury or other musculoskeletal injury
DM1.4. Cardiovascular disease
DM1.5. Cancer or cancer survivorship
DM1.6. Diabetes or pre-diabetes
DM1.7. Depression
DM1.8. High risk pregnancy
DM1.9. Hypertension or high blood pressure
DM1.10. High blood cholesterol
DM1.11. Obesity
DM1.12. Migraine/headache
DM.1.13. Excessive alcohol/drug use or abuse

DM2.a. Thinking about all of the disease management programs offered to employees at this worksite, were they usually offered…

Onsite in-person

By phone counseling

Online program

Multiple ways

Don’t know

Refused

DM2.b. Think about all of the disease management programs offered to employees at this worksite. Would you estimate the usual level of employee participation as:

1-25%

26-50%

51-75%

More than 75%

Don’t know

Refused

DM2.c. Did your organization provide any training for managers/supervisors about disease management topics? (e.g., training on how to recognize the disease, productivity/safety issues, and/or company/community resources for managing this disease?)

Yes

No

Don’t know

Refused

DM3. During the past 12 months, have you had an onsite health clinic available for employees at this worksite location?

Yes

No

Don’t know

Refused

KEY PARTNERS, INCENTIVES, PROGRAM IMPLEMENTATION & EVALUATION

Now we are going to ask a few questions about the groups or organizations or vendors you may typically partner with in order to offer employee health promotion/wellness programs.

KP1. During the past 12 months, did you partner with any of the following to offer health programs for your employees?	Yes	No	Don’t know	Refused
KP.1.a. State/local public health agency
KP.1.b. Health insurance plan
KP.1.c. Health management program and/or wellness program provider/vendor
KP.1.d. Workers compensation provider
KP.1.e. Health related organization (e.g. Am Heart Association, Am Cancer Society)
KP.1.f. Health insurance broker
KP.1.g. Hospital
KP.1.h.YMCA
KP.1.j. Community organization or business group (Wellness Council, Chamber of Commerce or other business group)
KP.1.k. Other (please specify)_________________________

Next we will ask about incentives you may offer to employees. In this section, you can think of incentives broadly – including incentives that are used to reward participation or behavior change, or, penalize employees for not improving health behaviors.

KP2. During the past 12 months, have you offered any incentives related to the health promotion/wellness programs you have offered to your employees?

Yes, we have offered incentives

No, we have not offered incentives, but we plan to in the next 12 months

No, we have not offered incentives and have no plans to offer them in the next 12 months

Don’t know

Refused [IF NO, DK, REF – Skip to WL1.]

KP3. How did you use any type of incentive supporting your employee health promotion/wellness program in the past 12 months? Did you offer incentives that were…	Yes	No	Don’t know	Refused
KP3.1. Tied primarily to participation or attendance in a health programs?
KP3.2. Tied primarily achieving a particular health standard?
KP3.3. Tied to both participation and achieving a health standard?

[IF YES TO ANY KP3. Ask KP4.

If NO to ALL KP3, skip to KP5].

KP4. We understand that many factors influence whether employees achieve certain health goals, but if you were to focus solely on the use of incentives, how effective were the incentives you offered for achieving their intended outcome?

Not at all effective

Somewhat effective

Effective

Extremely effective

Don’t know

Refused

KP5. What type of incentives did you use in the past 12 months at this worksite location?	Yes	No	Don’t know	Refused
KP5.a. Premium discounts
KP5.b. Copay differences
KP5.c. Coinsurance (the percentage the employee pays after the policy deductible is met) differences
KP5.d. Cash rewards
KP5.e. Add money to flexible spending accounts
KP5.f. Additional paid time off
KP5.g. Gifts
KP5.h. Prizes
KP5.i. Other (Please specify _____________________________)

WORK-LIFE PROGRAMMING, POLICIES AND BENEFITS

WL1. During the last 12 months, did this organization or your health plan offer an Employee Assistance Program (EAP) to employees and/or their families?

Yes, for employees

Yes, for employees and their families

No

Don’t know

Refused [If NO to WL1, Skip to WL2]

Does the EAP offer…	Yes	No	Don’t know	Refused
WL1.1. Screening, referrals and/or brief interventions for excessive alcohol use?
WL1.2. Screening and referrals to specialized treatment programs for alcohol dependence?
WL1.3. Screening, referrals and/or brief interventions for substance abuse?
WL1.4. Screening, referrals and/or brief interventions for stress, anxiety and/or depression?
WL1.5. Screening, referrals and/or brief interventions to identify, prevent and/or treat domestic violence?

WL2.During the past 12 months, did your worksite provide training to prevent bullying or violence in the workplace?

Yes

No

Don’t know

Refused

WL3. During the past 12 months, did this worksite location provide employees with a paid time off (PTO) plan? (Note: A paid time off (PTO) plan includes vacation, sick and personal leave in one comprehensive benefit.)

Yes

No

Don’t know

Refused [If No, DK, REF to WL3., Skip to WL4.]

WL3.a. Does the paid time off/PTO plan include any of the following:

(Select all that apply)

Paid sick hours or days

Paid personal hours or days

Paid vacation hours or days

None

Other (please specify)______________

Don’t know

Refused

During the past 12 months, did this worksite location…	Yes	No	Don’t know	Refused
WL4. Provide employees paid time off for hours/days due to illness of the employee or dependents (e.g. paid sick time)?
WL5. Offer employees flexible work schedules (Note: flexible schedules can include allowing employees to choose their own starting and quitting times within a range of hours, working compressed work weeks, teleworking and job sharing)?
WL6. Allow employees to work from home?
WL7. Offer disability leave or disability insurance?
WL8. Offer paid family leave for new parents? (Note, this includes paternity, maternity and adoption leaves)
WL9. Allow employees to take unpaid parental leave?
WL10. Provide information to employees about child care services in the community?
WL11. Help employees cover any costs of child care for their children by directly reimbursing for costs or by providing a flexible spending account?
WL12. Offer on-site or off-site child care for employees?
WL13. Provide information to employees about eldercare services in the community?
WL14. Help employees cover any costs of eldercare?
WL15. Offer on-site or off-site eldercare for employees?

PROGRAM BARRIERS

B1. Thinking across all types of employee health promotion/wellness programs, please rate the following on the extent to which each has been a barrier or challenge to this worksite in offering these programs?	1=Not at all challenging to 5= Extremely challenging
	1-Not at all Challenging	2-Slightly Challenging	3-Somewhat Challenging	4- Challenging	5-Extremely Challenging	Don’t know	Refused
B1.1. Lack of employee interest
B1.2. Employee distrust of employer-sponsored programs
B1.3. Lack of participation by high-risk employees
B1.4. Cost (e.g. lack of funds)
B1.5. Lack of trained and experienced staff
B1.6. Conflicting or competing business demands
B1.7. Conflicting or competing employee work-life demands
B1.8. Concern about confidentiality/privacy
B1.9. Lack of access to data (medical, Rx claims, disability, HRA)
B1.10. Lack of integration with other programs/services
B1.11. Demonstrating program results
B1.12. Lack of qualified vendors
B1.13. Lack of senior management support
B1.14. Lack of middle management or supervisor support
B1.15. Changes in the regulatory environment (e.g. HIPAA, ADA, etc.)
B1.16. Legal concerns
B1.17. Lack of physical space at work

B2. Of all the barriers or challenges you identified in the previous question, what are the TOP 3 most difficult to overcome when trying to offer health promotion programs at this worksite?

1.________________________2.__________________________3._____________________________

OCCUPATIONAL SAFETY AND HEALTH

The next questions will ask about safety-related programs at this worksite location.

OSH1. Is there at least one dedicated person who is responsible for the safety of employees at this worksite location?

Yes

No

Don’t know

Refused [If NO, DK, REF – skip to OSH3]

OSH2. Does the person who is responsible for employee safety also have responsibility for promoting health/wellness at this worksite location?

Yes

No

Don’t know

Refused

Does this site…	Yes	No	Don’t know	Refused
OSH3. Have a written injury and illness prevention program?
OSH4. Have a policy requiring or encouraging the reporting of worksite injures and near misses, and illnesses?
OSH5. Provide opportunities for employee input on hazards and solutions to reduce or eliminate those hazards?
OSH6. Provide new employees with formal training on how to avoid on-the-job accidents, injuries, and illnesses?

Total Worker Health is a strategy that INTEGRATES occupational safety and health with other workplace programs that prevents worker injury and illness and promotes employee health and well-being at work.

Are these examples of INTEGRATED programs present at your worksite location?	Yes	No	Don’t know	Refused
OSH7.1 Senior leadership who demonstrates commitment to both safe work design and worker well-being.
OSH7.2. Plan for initiatives that jointly protect worker health, safety and well-being.
OSH7.3. Efforts to protect and promote worker health include changes to improve work design and the work environment, along with educating individual workers.
OSH7.4. Efforts to protect and promote worker health that include training of supervisors.
OSH7.5.Employees and management work together to set priorities, plan, implement and evaluate both safety and health promotion programs.
OSH7.6. Communication and programming that protects worker health is included with efforts to promote employee well-being.
OSH7.7. Decision-making about policies, programs and practices related to worker health is coordinated across departments, including those responsible for occupational safety and health and those responsible for health promotion.

The next few questions ask about employees based at this worksite who may work outdoors.

OSH8. Does this site employ individuals who work outdoors?

Yes

No

Don’t know

Refused [If NO, DK, REF to OSH8. – skip to E1.]

OSH8.1 Does this site offer any of the following that relate to sun protection/skin cancer prevention?	Yes	No	Don’t know	Refused
OSH8.1.a. Educational information about sun protection to workers through instruction, posters, or brochures?
OSH8.1.b. Environmental approaches to encourage sun protection (e.g. provide sunscreen or shade)?
OSH8.1.c. Policies to support sun protection practices (e.g. require sun protective behavior)?

EMERGING ISSUES

E1. What training or technical assistance topics would be most useful for the people responsible for promoting employee health/wellness and safety at your worksite? (check all that apply)

Best practices for employee safety and health promotion

Conducting health and safety risk assessments

Documenting health improvements and cost impacts of wellness and safety programs

Laws, regulations, policies and standards related to workplace health and safety programs

Health care insurance, coverage, workers compensation, and claims processes

Partnership building, integration, coordination and collaboration

Leadership and management engagement (Communication, marketing and advocacy)

Program planning, implementation and evaluation skills

Other (please specify)__________________________________________

E2. To what extent do you believe that employees work within a “culture of health” at this worksite location? (Note: a workplace culture of health is one in which leadership that creates a work environment that values and supports employee health and provides healthy work conditions as the normal way of doing business.)

|------------|------------|------------|------------|------------|------------|------------|------------|------------|

1 2 3 4 5 6 7 8 9 10

Not at all Completely

E3. To what extent do you believe that your worksite location has intentionally connected with community-based programs that might benefit the health of employees and their families?

|------------|------------|------------|------------|------------|------------|------------|------------|------------|

1 2 3 4 5 6 7 8 9 10

Not at all Completely

E4. Are there any other issues we have not yet discussed related to employee health/wellness or safety at your work location that would like to be sure we understand?

WORKFORCE DEMOGRAPHICS

For each question below, please estimate the percentage using 0-100%. Please estimate if you do not have precise percentages.

Considering ALL (full and part-time) employees at this worksite location, what percentage…	Percentage	Don’t know	Refused
WD1.1 Are under age 30?
WD1.2 Are age 30-49?
WD1.3 Are age 50-69?
WD1.4 Are age 70 or older?
WD2. Are female?
WD3. Are racial/ethnic minorities (e.g., non-Caucasian)?
WD5. Are hourly/non-exempt workers?
WD5. Work something OTHER THAN a typical daytime shift (e.g., 9-5, 7-3) or during normal business hours?
WD6. Regularly work remotely or off-site?
WD7. Are under collective bargaining or unionized?
WD8. Are “disabled” according to ADA guidelines (i.e., need accommodations at work)?
WD9. What is the average annual percentage of turnover at this worksite location?

39