Tri Wellness at Work Interest Form

If any assistance is needed, please contact us:

Kristy Heying: kristy.heying@co.sherburne.mn.us or 763-765-4106
Mariah Klein: mklein@co.benton.mn.us or 320-968-5250
Melissa Godwin: melissa.godwin@stearnscountymn.gov or 320-656-6141

Expectations for Tri Wellness at Work Participants:

The 6-8 month learning phase typically begins in fall/winter.
Typically, meetings are held monthly and in-person and are approximately 2 hours long.
One employee from each organization must attend every monthly meeting (if the main contact cannot attend, the organization must provide a back up person). It is highly recommended to have two contacts from each organization.
Complete assessments, workplan, and evaluation, gain leadership support, and create a wellness committee. Technical assistance from SHIP staff will be available.

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* 1. Organization Name

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* 2. Organization's Main Physical Address (street address, city/town, state, zipcode)

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* 3. Select the type of industry that best describes your organization (select one):

Accommodation and food services

Administrative and support and waste management and remediation services (e.g., office cleaning and maintenance businesses, temporary employment agencies, mold remediation businesses)

Agriculture, forestry, fishing, and hunting

Arts, entertainment, and recreation

Construction

Educational services

Finance and insurance

Health care and social assistance

Information

Management of companies and enterprises

Manufacturing

Mining, quarrying, oil/gas extraction

Professional, scientific, and technical services

Public administration

Real estate rental and leasing

Retail trade

Transportation and warehousing

Utilities

Wholesale trade

Other (please specify):

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* 4. Total Number of Employees

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* 5. Do any of the following apply to your organization? (select all that apply)

Employ 42% or more of adults over the age of 45

Do not offer health care benefits

Employ a significant number of workers with limited English or non-English workers

Employ a significant number of workers with limited education

Do not know

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* 6. Primary Contact Information

First and Last Name

Email Address

Phone Number

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* 7. Does your organization currently have a work site wellness or employee wellness program?

Yes

Comments:

Tri Wellness at Work Interest Form

Question Title

* 1. Organization Name

Question Title

* 2. Organization's Main Physical Address (street address, city/town, state, zipcode)

Question Title

* 3. Select the type of industry that best describes your organization (select one):

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* 4. Total Number of Employees

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* 5. Do any of the following apply to your organization? (select all that apply)

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* 6. Primary Contact Information

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* 7. Does your organization currently have a work site wellness or employee wellness program?

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* 8. Please list any questions/comments you have for us or other information you would like us to know about your work site: