Community Transformation Grant - Worksite Wellness Survey

Peoria and Tazewell counties are collaborating with the help of Quality Quest to bring worksite wellness to our area businesses. Please take some time to fill out the survey. Once you have completed the survey some evaluation will be done to better understand your needs and present you with the tools needed to better your program or help establish a worksite wellness program at your business. Worksite wellness programs have many proven benefits so with your help we can make Peoria and Tazewell counties a healthier place to live.

Funding for this survey was made possible by grant #1H75DP004385-01 from the Centers for Disease Control and Prevention (CDC).

Survey created through the collaboration of Quality Quest, Central Illinois Wellness Council, Peoria City/County Health Department, UICOMP, Hult Center for Healthy Living, Tazewell County Health Department, OSF Saint Francis Medical Center, and Unity Point Health/Methodist.

Question Title

* 1. Contact information

Business/Company Name

Business Address

Telephone Number

Your First Name

Your Last Name

Job Title

Division/Department

Email Address

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* 2. What is your organizations industry type?

	Industries
Organization Industry	Organization Industry Industries menu

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* 3. Number of employees

Total

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* 4. Percentage of male and female employees?

Female

Male

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* 5. Percentage of employees by age

< 18

18-34

35-44

45-64

> 65

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* 6. Percentage of part-time and full-time employees.

Full Time

Part Time

Temporary

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* 7. Is health insurance coverage available for your employees?

Yes

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* 8. Do you currently have an active worksite wellness policy?

Yes

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* 9. Do you have a worksite wellness committee that meets regularly?

Yes

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* 10. Tobacco: Does your organization...

	Yes	NO
Have a written policy banning tobacco use at your workplace?	Have a written policy banning tobacco use at your workplace? Yes	Have a written policy banning tobacco use at your workplace? NO
Actively enforce a written policy banning tobacco use?	Actively enforce a written policy banning tobacco use? Yes	Actively enforce a written policy banning tobacco use? NO
Display signs (including no smoking signs) with information about your tobacco policy?	Display signs (including no smoking signs) with information about your tobacco policy? Yes	Display signs (including no smoking signs) with information about your tobacco policy? NO
Refer tobacco users to a state or other tobacco cessation telephone quit line?	Refer tobacco users to a state or other tobacco cessation telephone quit line? Yes	Refer tobacco users to a state or other tobacco cessation telephone quit line? NO
Promote or provide free or subsidized tobacco cessation counseling?	Promote or provide free or subsidized tobacco cessation counseling? Yes	Promote or provide free or subsidized tobacco cessation counseling? NO
Inform employees about health insurance coverage or program that include tobacco cessation medication and counseling?	Inform employees about health insurance coverage or program that include tobacco cessation medication and counseling? Yes	Inform employees about health insurance coverage or program that include tobacco cessation medication and counseling? NO
Provide incentives for being a current nonuser of tobacco and for current tobacco users that are currently involved in a cessation class or actively quitting?	Provide incentives for being a current nonuser of tobacco and for current tobacco users that are currently involved in a cessation class or actively quitting? Yes	Provide incentives for being a current nonuser of tobacco and for current tobacco users that are currently involved in a cessation class or actively quitting? NO

Question Title

* 11. Provide health insurance coverage with no or low out-of-pocket costs for...

	Yes	No
Prescription tobacco cessation medications including nicotine replacement?	Prescription tobacco cessation medications including nicotine replacement? Yes	Prescription tobacco cessation medications including nicotine replacement? No
FDA-approved over-the-counter nicotine replacement products?	FDA-approved over-the-counter nicotine replacement products? Yes	FDA-approved over-the-counter nicotine replacement products? No

Question Title

* 12. Nutrition: Does your organization?

	Yes	No
Provide places to purchase healthy food and beverages?	Provide places to purchase healthy food and beverages? Yes	Provide places to purchase healthy food and beverages? No
Have a written policy or formal communication that makes healthier food and beverage choices available in cafeterias, snack bars or vending machines?	Have a written policy or formal communication that makes healthier food and beverage choices available in cafeterias, snack bars or vending machines? Yes	Have a written policy or formal communication that makes healthier food and beverage choices available in cafeterias, snack bars or vending machines? No
Make most (more than 50%) of the food and beverage choices available in vending machines, cafeterias, snack bars, or other purchase points be healthier food items?	Make most (more than 50%) of the food and beverage choices available in vending machines, cafeterias, snack bars, or other purchase points be healthier food items? Yes	Make most (more than 50%) of the food and beverage choices available in vending machines, cafeterias, snack bars, or other purchase points be healthier food items? No
Identify healthier food and beverage choices with signs or symbols?	Identify healthier food and beverage choices with signs or symbols? Yes	Identify healthier food and beverage choices with signs or symbols? No
Provide employees with food preparation and storage facilities?	Provide employees with food preparation and storage facilities? Yes	Provide employees with food preparation and storage facilities? No
Offer or promote an on-site or nearby farmers market where fresh fruits and vegetables are sold?	Offer or promote an on-site or nearby farmers market where fresh fruits and vegetables are sold? Yes	Offer or promote an on-site or nearby farmers market where fresh fruits and vegetables are sold? No
Provide free or subsidizing self-management programs for healthy eating?	Provide free or subsidizing self-management programs for healthy eating? Yes	Provide free or subsidizing self-management programs for healthy eating? No

Question Title

* 13. Physical Activity: Does your organization...

	Yes	No
Provide an exercise facility on-site?	Provide an exercise facility on-site? Yes	Provide an exercise facility on-site? No
Subsidize or discount the cost of on-site or off-site exercise facilities?	Subsidize or discount the cost of on-site or off-site exercise facilities? Yes	Subsidize or discount the cost of on-site or off-site exercise facilities? No
Provide other environmental supports for recreation or physical activity?	Provide other environmental supports for recreation or physical activity? Yes	Provide other environmental supports for recreation or physical activity? No
Post signs at elevators, stairwell entrances or exits and other key locations that encourage employees to use the stairs?	Post signs at elevators, stairwell entrances or exits and other key locations that encourage employees to use the stairs? Yes	Post signs at elevators, stairwell entrances or exits and other key locations that encourage employees to use the stairs? No
Provide organized individual or group physical activity programs for employees (other than the use of an exercise facility)?	Provide organized individual or group physical activity programs for employees (other than the use of an exercise facility)? Yes	Provide organized individual or group physical activity programs for employees (other than the use of an exercise facility)? No
Provide or subsidize physical fitness assessments, follow-up counseling, and physical activity recommendations either on-site or through a community exercise facility?	Provide or subsidize physical fitness assessments, follow-up counseling, and physical activity recommendations either on-site or through a community exercise facility? Yes	Provide or subsidize physical fitness assessments, follow-up counseling, and physical activity recommendations either on-site or through a community exercise facility? No

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* 14. Clinical Prevention Services: Does your organization provide...

	Yes	No
Blood pressure screenings	Blood pressure screenings Yes	Blood pressure screenings No
Cholesterol screenings	Cholesterol screenings Yes	Cholesterol screenings No
Fasting Blood Sugar	Fasting Blood Sugar Yes	Fasting Blood Sugar No
Bone density	Bone density Yes	Bone density No
BMI/Body Fat assessment (height and weight measurements)	BMI/Body Fat assessment (height and weight measurements) Yes	BMI/Body Fat assessment (height and weight measurements) No
Breast Cancer Screenings - Mammography	Breast Cancer Screenings - Mammography Yes	Breast Cancer Screenings - Mammography No
Colon Cancer Sceenings	Colon Cancer Sceenings Yes	Colon Cancer Sceenings No
Cervical Cancer Screenings - Pap Smear	Cervical Cancer Screenings - Pap Smear Yes	Cervical Cancer Screenings - Pap Smear No

Question Title

* 15. Does your organization provide a series of educational seminars, workshops, or classes on...

Tobacco Cessation

Nutrition and Healthy Eating

Physical Activity

Clinical and Prevention Services

Other - please list:

Question Title

* 16. Does your organization provide brochures, videos, flyers, emails, newsletters, posters, or other written or online information that address...

Tobacco Cessation

Nutrition and Healthy Eating

Physical Activity

Clinical and Preventive Services

Other - please list:

As completion of this survey we will follow up with a workplace wellness toolkit that will provide information and assistance in developing or bettering a workplace wellness program. If you have any questions please contact Ashley Musselman at the Hult Center for Healthy Living at 309-692-6650 or Kayla Goldsworthy at Tazewell County Health Department at 309-925-5511.