Workplace Health and Well-being – Sample Workplace Health and Well-being Survey Fact Sheet

WHAT IS AN EXAMPLE OF A WORKPLACE HEALTH AND WELL-BEING SURVEY?

Workplaces often use a survey form to determine interest in the various aspects of a workplace health and well-being program. The following is a sample. Be sure to customize it for your needs at your workplace.

Sample Workplace Health and Well-being Survey

ABC Company is looking into the need for a workplace health and well-being program. We are interested in learning more about your opinions and interests. Your answers will be used to help plan the program and to decide which types of programs to offer.

Senior management has agreed to let everyone take a few minutes to complete this survey.
Please do not put your name on the form because we would like to keep this survey confidential.
Please return the forms by putting them in a sealed envelope and placing them in the inter-office mail.

1. Sex:

Male Female

2. Age Group:

under 21 21 – 30 31 – 40

41 – 50 51 – 60 over 60

3. Do you have any health concerns about yourself, your family, or something arising from the workplace?

4. Would you like ABC Company to help with these concerns?

Yes No Not sure

Explain your answer

5. Indicate how you feel about the following statements:

	Agree Strongly	Agree	Not sure/ No opinion	Disagree	Disagree Strongly
On the whole, I like my job.
I feel that I am well rewarded for the effort I put in at work.
I am happy with the balance between my work time and my leisure time.
At work, my level of authority is about the same as my level of responsibility.

6. Which of the following activities would you prefer to participate in? (Check all that you would be likely to join)

	Yes	No	Maybe
Aerobic exercise
Walking Club
Recreational Team (e.g., baseball)
Other exercise programs (specify)
Healthy Backs
Healthy Eating (general tips, etc.)
Weight Management
Blood Cholesterol Testing
Flu Shots
Blood Pressure Screening
Blood Glucose Screening
Body/Mass Index (BMI) Testing
Stress Management (either home/work)
Alcohol / Drug Abuse Education
Smoking Cessation
Parenting
Marital Situations
Interpersonal Skills (such as “Dealing with Difficult People”, Conflict Resolution, etc.)
Retirement Planning
Lunch & Learn Sessions
Time Management
Home Budgeting / Financial Planning
Health Fair (booths)
Balancing Family and Work
Other: (please list)

7. When would you be able to participate?

Day of the Week	Season	Time Period
Monday	Spring	Before work
Tuesday	Summer	Lunch time
Wednesday	Fall	After work
Thursday	Winter	Evenings
Friday	Other
Weekends (for family events)

8. Where would you prefer to attend a program?

Work
Private Health Club
Local School or Facility/Hall
Other

9. If necessary, would you be willing to share in the cost of a program?

Yes No

10. Do you have any additional comments or concerns you would like the committee to know?