Health & Wellness Survey
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1. Default Section

 
Thank you for taking a couple minutes to complete this brief, ten question survey.

All information will remain confidential and will be used (in aggregate form only) for our grant-funded research and outcomes study on health and wellness professionals' willingness and readiness to collaboratively work with employers in their communities.

Once you have completed the survey, a Consultant will contact you to review grant-funded opportunities to get involved with a Community-Based Initiative (CBI) in your area. Ultimately, the Consultant will help you understand how well positioned you are to be a resource for local employers and their employees based upon what employers are looking for in behavioral risk identification and mitigation strategies that qualify for private and governmental grant funding.

As we are currently needing Wellness Educators, Coaches, and Consultants, we'll be able to determine together if you should be involved with our grant-funded initiative in your community.

More information is available on www.healthypeople2010grant.org.

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1. Referred by:

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2. Please provide us some basic information about you/your organization.

3. Please provide your fax number.

Wellness, Prevention & Risk Management Components

4. Help us understand what involvement you have with area employers currently. Please note, this question is specific to what you do with employers--NOT in general.

 Currently DoPlanning To Begin Doing In The Next 12 MonthsDon't Do And No Interest In Doing
Corporate Health Fairs
Corporate Health Screenings
Corporate Health Talks/Lunch & Learns
Small Group Health Improvement Classes
One-On-One Health Coaching
Growth Goals

5. What percentage of growth are seeking to accomplish during the next twelve months?

6. What are your "core" services, programs, or products that you are looking to increase the volume of the most through employer relationships? Specifically, "core" services, programs, or products represent what you already do, want to do more of, and find profitable to do. For a Chiropractor, a core item might be chiropractic adjustments. For a personal trainer, it might be personal training. For some, it might be nutritional supplementation.

7. How many new employer relationships would you like to have within the next 12 months?

8. Please identify your "hot list"--three employers that you would most like us to get involved in the Healthy People Grant so you can work with them and their employees?

9. What is your budget to accomplish your growth goals (question 6) and to develop the desired employer relationships (question 7)?

Now we need to understand how you'd fit into your local Community-Based Initiative. Not what services you provide but, instead, the behavioral and lifestyle risks that you have the ability to address.

Based upon your responses and program participation, you'll be added to the local Resource Listing that is used by employers, employees, and family members as well as being eligible to be a guest speaker and receive referrals on areas of competency.

10. How can you help people?

 Currently DoPlanning To Begin DoingInterested In Doing But Don't Have A PlanNot Interested In Doing
Adolescent/Children's Health Issues
Anti-Aging
Bio-Metric Screenings
Disease Management
Elevated Blood Pressure
Elevated Cholesterol
Elevated Glucose (Pre-Diabetes)
Financial Wellness/Preparedness
Health Coaching (One-On-One)
Health Coaching (Small Group Classes)
Identity Theft Protection
Improved Fitness
Improved Mood/Happiness
Improved Nutrition
Legal Wellness/Preparedness
Men's Health Issues
Sleep Health Issues
Smoking Cessation
Stress Reduction/Management
Weight Loss/Management
Women's Health Issues

11. As part of the CBI, we are creating a local Speaker's Bureau. If you'd like to educate groups of employees, please list your preferred three topics to speak on.

12. Let us know anything else that you'd like us to know about yourself, your interests, etc.

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