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* 1. Optional: Provide your contact information and be entered to win a $50 gift card to a local restaurant! Your contact information will not be included with the survey results.

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* 2. Please tell us where you work.

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* 3. Please provide your current department or school site.

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* 4. Which gender to you identify with?

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* 5. I am a:

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* 6. Are you participating in the Wellness Incentive Program?

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* 7. If you are not participating in the wellness program please tell us why.

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* 8. Please rate how you feel about the following statements: My workplace has provided me with the opportunity to:

  Strongly Agree Agree Disagree Strongly Disagree Unsure
Be physically active
Learn about nutrition
Reduce my stress
Work in a tobacco free environment
Work in a safe environment

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* 9. Please rate how you feel about the following statements?

  Strongly Agree Agree Disagree Strongly Disagree Unsure
I know which activities, events, and classes are worth wellness points.
I know how to record my wellness points.
I knew that family members 12 yrs old and up are able to attend wellness classes and events.
I knew non-benefited employees could participate in wellness classes and events.

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* 10. Please select all that apply

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* 11. The wellness program is considering offering online fitness & yoga classes that could be done at home without exercise equipment. Please select all that apply below.

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* 12. Please rate how you feel about the following statements?

  Strongly Agree Agree Disagree Strongly Disagree Unsure
The Wellness Program classes, challenges, or events have helped me maintain improvements to my health for 6 months or more.
I would participate in the wellness classes, events, and challenges even if they were not worth wellness points. 

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* 13. Please rate how you feel about the following statements?

  Strongly Agree Agree Disagree Strongly Disagree Unsure
I feel encouraged by my direct management to participate in the Wellness Program, classes, or events.
My co-workers support my efforts to be healthy.
I would recommend my place of work to someone looking for a job.
My direct management knows how to positively motivate me.
Health and wellness is a common topic at my place of work. 
I feel I can take time off when needed for my personal life. 
The leadership/senior management of my workplace are obvious supporters of the Wellness Program.
My direct management participates in the Wellness Program.

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* 14. Please rate how you feel about the following statements.

  Strongly Agree Agree Disagree Strongly Disagree Unsure
I have a positive attitude more often that not.
I am engaged at work more often than not.
I find meaning in my job.
I have goals in life I am working toward.
I have co-workers that I trust.
I eat healthy more often than not.
I get enough sleep more often than not.
I get enough exercise more often than not.

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* 15. Overall, I am satisfied with the Wellness Program

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* 16. I wish the wellness program offered...

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* 17. If you have not been to the clinic please tell us why:

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* 18. Please rate how you feel about the following statements?

  Strongly Agree Agree Disagree Strongly Disagree Unsure
I know where the Vera Clinic is located.
I know how much it will cost me to go to the Vera Clinic.
The Vera Clinic has been a great addition to my employee benefits.
I am able to get an appointment at the Vera Clinic when I need one.
The staff at the Vera Clinic are friendly and nice

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