1.Do you have a Wellness Program/Team at your site?

Yes

No

2.If so, does the Wellness Program/Team have a budget?

Yes

No

3.Is the Wellness Program/Team employee led?

Yes

No

4.Does your site have a Wellness Center or gym?

Yes

No

5.If yes, is it staffed?

Yes

No

6.What types of activities are supported by your Wellness Center or gym?

1

2

3

4

5

6

7

8

7.What are the primary goals of your wellness program?

1

2

3

4

5

8.Contact information

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number