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

Name/Liaison

Phone Number

Fax

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* 2. Worksite

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* 3. Worksite Address

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?

Yes

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* 5. Has your worksite provide brochures, videos, posters, pamphlets, newsletters, or other written or online information that address the benefits of healthy eating?

Yes

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* 6. Has your organization hosted any training classes on nutrition?

Yes

Lactation Support

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* 7. Has your worksite written a breastfeeding policy for employees?

Yes

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* 8. Has your worksite provided a private space that may be used by an employee to express breast milk?

Yes

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* 9. Has your worksite provided flexible paid or unpaid break times to allow mothers to pump breast milk?

Yes

Screen Time

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* 10. Has your worksite encouraged stretch breaks instead of checking personal social media accounts?

Yes

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* 11. Has your worksite provided brochures on the effects of too much recreational screen time?

Yes

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* 12. Has your worksite ever participated in Screen-Free Week?

Yes

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.)?

Yes

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* 14. Has your worksite provided seminars, workshops, or classes on physical activity?

Yes

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* 15. Has your worksite posted signs to encourage physical activity?

Yes

Sugary Beverages

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* 16. Has your worksite replaced sugar-sweetened beverages for water during your breaks?

Yes

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* 17. Has your worksite provided water at staff meetings?

Yes

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* 18. Has your worksite promoted Rethink Your Drink (i.e. Drink water instead of soda)?

Yes

Tobacco

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* 19. Has your worksite written a smoke-free or tobacco-free policy?

Yes

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* 20. Has your worksite informed employees about health insurance coverage or programs that include tobacco cessation medication and counseling?

Yes

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* 21. Has your worksite referred employees to tobacco cessation classes or Quit Your Way?

Yes

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* 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!