Culture of Health Assessment Request Form

If you are ready to assess the culture of health for your worksite(s) in 2024, complete our registration form with preferred dates. The WebMD team will collaborate with you to either come onsite or meet virtually to complete an assessment. The next step includes a report and review meeting with recommendations. There are no out-of-pocket costs for your organization, as this resource is included in the Well Wisconsin program. Please submit requests at least 14 days before the assessment date to allow time for coordination of schedules. If you have questions, contact the WebMD team at wellwi-employersupport@webmd.net.

Question Title

* 1. Requester's Contact Information

Name

Organization Name

Email Address

Phone Number

Question Title

* 2. Employer Group

Local Employer

State Agency

Universities of Wisconsin

UW Health

Question Title

* 3. Preferred date and start time for onsite culture of health assessment

First choice

Date

Time

AM/PM

Second choice

Date

Time

AM/PM

Third choice

Date

Time

AM/PM

Question Title

* 4. Health assessment completion preference

Onsite meeting

Virtual meeting