1. Overall, how have participation rates in your wellness program changed over the past two years?

• Remained about the same

• Increased modestly

• Increased substantially

• Declined modestly

• Declined substantially

• Doesn’t apply, we are just getting started

2. What department is your wellness program located in?

• Human Resources
• Marketing
• Medical/Occupational Health
• Health Promotion
• Safety
• Other (please explain)

3. How many employees does your organization have?

• Under 50 
• 50-100
• 101-500 
• 501-1,000
• 1,000-4,999 
• 5,000+

4. What type of industry best classifies your organization?

• Manufacturing
• Wholesale/Retail
• Services
• Transportation
• Communication
• Utilities
• Agricultural
• Mining
• Construction
• Other (please list)

5. What is the approximate annual budget of your current wellness initiative?

6. Which statement(s) best describes the reason why your organization started a wellness initiative? (Check all that apply)

• To improve teamwork/morale

• To enhance productivity

• To meet our employees’ requests

• To improve the health and well-being of our employees

• To contain costs

• To improve recruitment/retention

• To reduce absenteeism

• Other (please explain)

7. Support for our organization’s wellness initiative is demonstrated by the fact that: (please answer yes or no)

• Our CEO genuinely believes in the value of worksite wellness.

• A statement concerning employee health and well-being has been incorporated into the company’s vision/mission statement.

• Our CEO has communicated the importance of wellness to all employees (e.g. formal written memo, incorporated into orientation, public addresses, etc.).

• The company has formally appointed an individual(s) and/or a committee to lead the wellness initiative.

• Senior level management allocates the necessary resources for the wellness program (e.g. budget, materials, people, space, etc.).

• Our CEO and senior level executives regularly take part in the activities offered.

• Middle level management supports the wellness program

• Middle level management regularly participates in wellness activities

1. A representative wellness committee involving the organizations’ key employees/constituents has been established (e.g. human resource/benefits, occupational health, MIS, etc.).

2. The wellness committee has developed a compelling vision, established strategic priorities, and defined individual roles and responsibilities.

3. The wellness committee has a strong and effective leader.

4. The wellness committee functions cohesively and effectively.

5. The wellness committee meets regularly throughout the year.

6. The proceedings of the meetings are consistently communicated to senior level executives.

• Carefully developed an operating plan that addresses our employee’s health needs and interests.

• Established clear, concise, and measurable goals and objectives that are linked to and supported by data.

• Linked our wellness goals and objectives to the organizations’ strategic priorities and outcomes.

• Incorporated specific timelines within the operating plan indicating when activities/tasks are to be completed.

• Assigned specific responsibilities to an individual or group for the completion of important tasks.

• Allocated an itemized budget sufficient to carry out the plan.

• Incorporated appropriate marketing strategies to effectively promote and communicate our programs to the employees and their dependents.

• A plan has been developed to evaluate the stated goals and objectives

11. To address the health needs and interests of our employees and their dependents, our organization has offered the following programs in the last 24 months: