2017 Wellness Survey

Dear Employees,

The purpose of this survey is to obtain your input for a new Wellness Program. This survey includes questions on your needs, interests and other pertinent information to determine what programs to offer.

* There is neither a right nor wrong answer for this survey
* Your completion of this survey is VOLUNTARY
* Your answers will remain completely ANONYMOUS

What is a Wellness Program?
Simply put, it is a program designed to help employees stay well. We would like to provide the tools and resources to allow our employees to lead a healthier life.

* 1. What is your age?

* 2. What is your sex?

* 3. Marital Status:

* 4. Do you have children living at home?

TOBACCO USE

* 5. Please read the statements below and select the answer that best describes your current tobacco use.

ALLERGIES

* 6. Do you have allergies?

* 7. If yes, what kind?

PROGRAM INTERESTS
We would like your input on possible worksite wellness program initiatives being considered.
Please mark which areas would be of interest to you.

* 8. Educational Programs:

* 9. Employee Assistance Program (EAP):

* 10. Smoking Cessation Program:

* 11. Stress Reduction Program:

* 12. Fitness Program:

* 13. Immunization and Prevention Program:

* 14. Nutrition Education Program:

INCENTIVES / REWARDS:

* 15. Please select which possible incentive would be most meaningful to you.

REMINDERS:

* 16. How would you like to be reminded of wellness events, participation, etc?

SUGGESTIONS:

* 17. List any suggestions you may have for health promotion programs.
Your input is an important element to the success of our program.

* 18. If you are interested in becoming a Wellness Champion or part of the Wellness Committee, please leave your name, email and phone number below.

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