Worksite Wellness Summit Question Title * 1. Please include your contact information. Name: Company: Email Address: Question Title * 2. Does your worksite have a program or policy in place that provides employees with health education, and access to healthy snacks / food options at worksite? Yes No Question Title * 3. Does your worksite have an onsite wellness program for employees? Yes No Question Title * 4. Does your wellness program include a wellness committee? Yes No Question Title * 5. Does your worksite currently have a breastfeeding policy? Yes No Question Title * 6. Does your worksite have a designated area for breastfeeding moms? Yes No Question Title * 7. Does your worksite currently have a smoke free indoor policy? Yes No Question Title * 8. Does your worksite currently have a tobacco free campus policy? Yes No Question Title * 9. Does your worksite currently offer a tobacco cessation program? Yes No Question Title * 10. Please rank your worksite wellness/ safety program:Use the following information to help you choose the most accurate answer…Key Elements of a comprehensive WHP Program1. Health Education (e.g., skills development and behavior-change classes; awareness building, such as brochures, posters)2. Links to related employee services (e.g., referral to Employee Assistance Program and or Early Symptom Programs)3. Supportive physical and social environments for health improvement (e.g., tobacco-free policies, subsidized gym membership)4. Integration of health promotion into the organizations culture (e.g., health promotion as part of a business mission statement)5. Employee screenings with adequate treatment and follow-up (e.g., Health Risk Assessments and biometric screenings) Level 1 – No program. Employer is motivated to start health, safety and or wellness program. Level 2 – Intermediate Program. Worksite has established health, safety and wellness program, with at least 1 or more elements of a comprehensive WHP program, but not all 5 elements. Level 3 – Established Program. Worksite has established health, safety and wellness program, with all 5 elements of a comprehensive WHP Program Question Title * 11. Is your worksite in the BRADD region? (Allen, Barren, Butler, Edmonson, Hart, Logan, Metcalfe, Monroe, Simpson, or Warren county, Kentucky) Yes No (please specify which area development district or county) If you have any questions or concerns please contact Elisha Delawson at elisha.delawson@barrenriverhealth.org or at 270 781 8039 ext 189. Done