03/14/2010
First Name       :
Email Address :
 
 
* CHECK ALL THAT APPLY
Physical Activity Environment
 
1. Does your worksite have stairs?
Yes
No
 
2. Does your workplace do anything to encourage stair use?
Yes
No
 
3. Is it convenient for your employees to walk or ride a bicycle to work?
Yes
No
 
4. Is it safe for your employees to walk or ride a bicycle to work?
Yes
No
 
5. Do you have lockers and/or showers at your workplace?
Yes
No
 
6. Do you have fitness equipment at your workplace?
Yes
No
 
7. Do you think your employees are putting this equipment to good use?
Yes
No
 
8. Do you provide discounts to employees who wish to exercise at an offsite recreation or fitness facility?
Yes
No
 
9. Do you support employee physical activity (such as allowing workers to take walking breaks, do pre-heavy-labor stretching, and take additional time off during lunch to exercise)?
Yes
No
 
10. Do your employees get adequate exercise at work as part of their job?
Yes
No
 
11. Do any employees participate in company sponsored team sports such as softball, etc.?
Yes
No
 
12. Are there any paths or trails near your worksite on which employees could walk during breaks, lunch or after work?
Yes
No
 
13. Has your worksite ever sponsored a local fun run or fun walk?
Yes
No
 
14. Does your worksite provide physical activity or exercise messages to the general employee population, such as posters or brochures?
Yes
No
 
 
Nutrition Environment
 
15. Do you have a cafeteria, snack bar, or catering truck that is available at your worksite?
Yes
No
 
16. Are healthy food alternatives (fruits, vegetables, whole grains breads, healthy beverages) available on a daily basis?
Yes
No
 
17. Do your food providers use healthy food preparation practices in the cafeteria (steaming, lowfat/salt substitutes, limited frying)?
Yes
No
 
18. Do you have vending machines on site?
Yes
No
 
19. Are fruits (dried or fresh), vegetables, low-fat snacks, or other “healthy” food alternatives usually available in your vending machines?
Yes
No
 
20. Do employees have access to a microwave at work?
Yes
No
 
21. Do employees have access to a refrigerator at work?
Yes
No
 
22. Does your worksite provide healthy eating messages to employees, such as posters or brochures?
Yes
No
 
23. Do you provide nutritious food and beverage options at company meetings and events?
Yes
No
 
 
Smoking Environment
 
24. Do you prohibit the hiring of smokers?
Yes
No
 
25. Do you have restrictions such as no smoking in company buildings, in company vehicles, or on company property?
Yes
No
 
 
Company Wellness Policy
 
26. Do you have a wellness committee?
Yes
No
 
27. Do you allow health promotion programs to be provided during company time (not lunch hour)?
Yes
No