Tri Wellness at Work Learning Series Registration Question Title * 1. Please provide your contact information: Name Company Address Address 2 City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Email Address Phone Number Question Title * 2. Number of employees at your workplace: Question Title * 3. Please select the webinar(s) you would like to register for: March 17th, 2022 9-10am: Healthy Eating and Breastfeeding Support April 12th, 2022 9-10am: Physical Activity May 19th, 2022 9-10am: Health Equity June 14th, 2022 9-10am: Tobacco Prevention July 14th, 2022 9-10am: Wellness Resources, Sustainability, and Evaluation Question Title * 4. Does your agency currently have an employee wellness program? Yes No Question Title * 5. Please indicate your wellness program's status with the following elements: Established Not Established In Progress Not Applicable Leadership support Leadership support Established Leadership support Not Established Leadership support In Progress Leadership support Not Applicable Wellness committee Wellness committee Established Wellness committee Not Established Wellness committee In Progress Wellness committee Not Applicable Program funding Program funding Established Program funding Not Established Program funding In Progress Program funding Not Applicable Developed mission/branding Developed mission/branding Established Developed mission/branding Not Established Developed mission/branding In Progress Developed mission/branding Not Applicable Written goals Written goals Established Written goals Not Established Written goals In Progress Written goals Not Applicable Written work plan Written work plan Established Written work plan Not Established Written work plan In Progress Written work plan Not Applicable Evaluation plan Evaluation plan Established Evaluation plan Not Established Evaluation plan In Progress Evaluation plan Not Applicable Regular assessments (surveys, health assessments, etc.) Regular assessments (surveys, health assessments, etc.) Established Regular assessments (surveys, health assessments, etc.) Not Established Regular assessments (surveys, health assessments, etc.) In Progress Regular assessments (surveys, health assessments, etc.) Not Applicable Done