1.Name of entity:

2.Number of fulltime employees:

3.Number of part-time employees:

4.Does your entity currently have an employee wellness program?

(A wellness program is one that is intended to improve and promote health for your employees that is offered through the workplace, online, via health plans or other vendors. Your program may or may not offer premium discounts, cash rewards, gym memberships, and other incentives to participate. Examples include programs to help you stop smoking, diabetes management programs, weight loss programs, and preventative health screenings. It may also include policies such as providing water and healthy foods at meetings and events.)

5.Describe what (if any) employee wellness policies your entity has initiated and what (where applicable) HEAL policies have been adopted?

6.How long has your wellness program been in place?

7.Please provide a brief description of the development of your entity's wellness program to date, or desire to develop a program.

8.Is there Leadership Support for Wellness? If yes, please describe what leadership does to support wellness at the entity. If not yet, what challenges exist to getting leadership support and/or what steps are you taking to garner the support.

9.Does your entity's current or proposed wellness program have an assigned coordinator or lead?

10.If yes, what is their title?

11.What percent of their job is dedicated to the wellness program?

12.If your entity does not have a wellness lead, please describe who is responsible for implementing and managing wellness programs and activities.

13.Does your entity have a budget for your current or proposed wellness program?

Yes

No

14.How much is your entity's current total annual budget or the estimated first-year budget for your proposed program?

15.Does your entity have a wellness program leadership team/steering committee?

(A leadership team/ steering committee is one that oversees strategic decisions for your program, including short-term and long-term goals and objectives as well as budget and resource allocation decisions. It may include a town/city manager or other leaders.)

Yes

No

16.Are both labor and management represented on the wellness program leadership team?

Yes

No

17.How often does the wellness program leadership team meet?

18.Does your entity have a wellness program committee? (A wellness program committee is a team that works together to plan and implement wellness activities. It can include a mix of management and employees as well as representatives from various departments or unions. In addition, a wellness program committee can include partners or third party vendors such as the entity's health plan carriers. A committee typically meets on a regular basis and is led by the wellness program coordinator, manager, or other entity employee.)

Yes

No

19.If your entity currently does not have an employee wellness committee or wellness program leadership team, how are wellness program decisions made in your entity? Please describe how you will seek input across departments, and how you will make decisions that impact multiple departments.

20.Does your entity have a group of wellness champions or advocates who are working with the wellness program committee or assigned coordinator/lead to engage employees and implement and/or support program activities and policies?

Yes

No

21.What departments are represented in your champions/advocates group?

22.How often does the group convene?

23.Briefly describe the group’s accomplishments to date.

24.Has your entity conducted any of the following audits, assessments, or surveys?

• An audit of the wellness environment and culture within the worksite (e.g., food and beverages offered in the cafeteria, vending machines, or served at meetings; the availability of bike racks, etc.)
• An assessment of the health risks of your employee population
• An assessment of the health risks of your employee population
• A survey to determine the needs and interests that your employees would like the program to address

If so, please describe the entity's completed audits, assessments, or surveys.

Regardless of whether formal assessments have been conducted, please also describe the top needs and interests your entity might want to address through its wellness program.

25.Has your entity identified goals and objectives for your wellness program?

Yes

No

26.Please state your goals and objectives for your wellness program.

27.Does your entity have a formal plan for your wellness program?

Yes

No

28.What period of time does the plan cover?

29.What are the plan's (or proposed plan's) key strategies?

30.Who in your entity approves current or proposed wellness plans?

31.Does your entity provide incentives to employees to participate in wellness program activities and/or for meeting certain wellness requirements?

Yes

No

32.Please describe how employees earn incentives for their participation in the program and/or for meeting certain wellness requirements.

33.Does your entity have mechanisms for communicating its wellness program to employees?

Yes

No

34.What communication mechanisms are used (e.g., website, email, flyers, etc.) and how often do employees receive communications through those mechanism?

35.Does your entity evaluate program results and outcomes?

Yes

No

36.Please describe what program evaluation method(s) your entity currently uses or might consider using in the future.

37.Please include your entity's primary point of contact information below

Name:

Title:

Email address:

Phone:

38.Is there any additional information you would like the Committee to consider in awarding this grant?