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HOW Assessment Survey
How healthy is your worksite? Choose the answer the best describes your work environment within the last 12 months. While there is no right or wrong answers, these questions can help you point your worksite wellness in the right direction.
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1.
Contact Information
(Required.)
Name/Liaison
Phone Number
Fax
Email
*
2.
Worksite
(Required.)
*
3.
Worksite Address
(Required.)
Address
City
State
Zip Code
Nutrition
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4.
Has your organization provided healthy snacks (i.e. fruits, vegetables, healthier food options, etc.) for meetings or celebrations?
(Required.)
Yes
No
*
5.
Has your worksite provide brochures, videos, posters, pamphlets, newsletters, or other written or online information that address the benefits of healthy eating?
(Required.)
Yes
No
*
6.
Has your organization hosted any training classes on nutrition?
(Required.)
Yes
No
Lactation Support
*
7.
Has your worksite written a breastfeeding policy for employees?
(Required.)
Yes
No
*
8.
Has your worksite provided a private space that may be used by an employee to express breast milk?
(Required.)
Yes
No
*
9.
Has your worksite provided flexible paid or unpaid break times to allow mothers to pump breast milk?
(Required.)
Yes
No
Screen Time
*
10.
Has your worksite encouraged stretch breaks instead of checking personal social media accounts?
(Required.)
Yes
No
*
11.
Has your worksite provided brochures on the effects of too much recreational screen time?
(Required.)
Yes
No
*
12.
Has your worksite ever participated in Screen-Free Week?
(Required.)
Yes
No
Physical Activity
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13.
Has your worksite provided organized individual or group physical activity programs for employees (i.e. walking club, physical activity challenges, etc.)?
(Required.)
Yes
No
*
14.
Has your worksite provided seminars, workshops, or classes on physical activity?
(Required.)
Yes
No
*
15.
Has your worksite posted signs to encourage physical activity?
(Required.)
Yes
No
Sugary Beverages
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16.
Has your worksite replaced sugar-sweetened beverages for water during your breaks?
(Required.)
Yes
No
*
17.
Has your worksite provided water at staff meetings?
(Required.)
Yes
No
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18.
Has your worksite promoted Rethink Your Drink (i.e. Drink water instead of soda)?
(Required.)
Yes
No
Tobacco
*
19.
Has your worksite written a smoke-free or tobacco-free policy?
(Required.)
Yes
No
*
20.
Has your worksite informed employees about health insurance coverage or programs that include tobacco cessation medication and counseling?
(Required.)
Yes
No
*
21.
Has your worksite referred employees to tobacco cessation classes or Quit Your Way?
(Required.)
Yes
No
*
22.
If your worksite has provided other health and wellness activities that aren't listed, please share your worksites activities. Thank you for your time!
(Required.)
