Work Well-Being Award Application 2024-2025

Please provide a response to each of the questions below and attach documentation where requested. Each wellness council may submit one application in this annual awards cycle. Applications will be accepted through May 5, 2025 and should describe one wellness activity or initiative implemented from May 4, 2024 - May 2, 2025.

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* 1. Organization Name

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* 2. Name of Your Wellness Council (If your council has a name)

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* 3. Number of employees at your worksite served by your wellness council or wellness efforts

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* 4. Name of person completing this application (contact person)

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* 5. Contact person's job title

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* 6. Contact person's email address

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* 7. Contact person's business phone number

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* 8. Organization's physical address

Organization

Street Address line 1

Street Address line 2 (optional)

City or Town

State

Zip Code

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* 9. How long has your wellness council been in place?

0-2 years

2-5 years

5-10 years

10 or more years

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* 10. Applicants are required to complete the Worksite Wellness Scorecard at least once every 2 years. What date did you most recently complete the Worksite Wellness Scorecard?

DD / MM / YYYY

Date

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* 11. Name the Wellness Activity or Initiative you are describing in this application

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* 12. The wellness activity or initiative described in this application addresses the following area(s) of well-being (you may select more than one area):

Career/Occupational Well-Being

Social Well-Being

Physical Well-Being

Emotional/Mental Well-Being

Financial Well-Being

Community Well-Being

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* 13. Please specify who an award check should be written to: Must include the organization's name, but may also include individual's name if desired. (for example: <Organization Name> OR <Individual Name>)

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* 14. To what address should a check be sent?

Organization

Attn:

Street Address 1

Street Address 2 (optional)

City or Town

State

Zip Code

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* 15. Is your organization or wellness council able to accept funds via Electronic Funds Transfer?

Yes

Not Sure

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* 16. In 1-3 paragraphs, describe the activity and how it was implemented. (For example, how did you decide to conduct this activity? What was the goal? How did you promote it? What was the timeline for planning and implementation? What resources were required?)

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* 17. Describe at least two positive outcomes that were a result of the activity or initiative (2-3 sentences)

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* 18. What lessons were learned that could help you as you plan future activities? (2-3 sentences)

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* 19. How did you evaluate the success of your activity? Include data or feedback that will demonstrate the impact or success of this activity (Number of participants, positive remarks, survey responses, etc.) (2-3 sentences)

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* 20. Provide documentation of your activity with attachments such as photos, flyers, promotional materials, email communication, etc. Please submit this in one PDF document and upload it here (maximum of 10 pages can be submitted).

Please submit documentation in one PDF preferably; other allowable formats include DOC/DOCx, PNG, JPG/JPEG. Google Docs are not acceptable. There is a 10-page maximum limit.

PDF, DOC, DOCX, PNG, JPG, JPEG file types only.

Choose File

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* 21. Please provide the name, title and email address of a senior manager at your organization that is aware of and supports your application.

Name

Title

Email address