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First Name
Email Address


PLEASE ANSWER YES OR NO TO EVERY QUESTION BELOW
Physical Activity Environment
1.
Does your work site have stairs?
YesNo

2.
Is it convenient for your employees to walk or ride a bicycle to work?
YesNo

3.
Is it safe for your employees to walk or ride a bicycle to work?
YesNo

4.
Do you have lockers and/or showers at your workplace?
YesNo

5.
Do you have fitness equipment or classes at your workplace?
YesNo

6.
Do you provide discounts to employees who wish to exercise at an offsite fitness facility?
YesNo

7.
Do you support employee physical activity such as allowing workers to take walking breaks, do pre-heavy-labor stretching, or take additional time off during lunch to exercise)?
YesNo

8.
Do your employees get adequate exercise at work as part of their job?
YesNo

9.
Do any employees participate in company sponsored team sports such as softball, etc.?
YesNo

10.
Are there any paths or trails near your worksite on which employees could walk during breaks, lunch or after work?
YesNo

11.
Has your worksite ever sponsored a local fun run or fun walk?
YesNo

12.
Does your worksite provide physical activity or exercise messages to employees, such as posters or brochures?
YesNo

Nutrition Environment
13.
Do you have a cafeteria, snack bar, or catering truck that is available at your worksite?
YesNo

14.
Do your food providers use healthy food preparation practices in the cafeteria (steaming, low-fat/salt substitutes, limited frying)?
YesNo

15.
Do you have vending machines on site?
YesNo

16.
Do employees have access to a microwave at work?
YesNo

17.
Do employees have access to a refrigerator at work?
YesNo

18.
Does your worksite provide healthy eating messages to employees, such as posters or brochures?
YesNo

19.
Do you provide nutritious food and beverage options at company meetings and events?
YesNo

Smoking Environment
20.
Do you prohibit the hiring of smokers?
YesNo

21.
Do you have restrictions such as no smoking in company buildings, in company vehicles, or on company property?
YesNo

Company Wellness Policy
22.
Do you encourage employees to get their preventive screenings each year?
YesNo

23.
Do you have a wellness committee?
YesNo

24.
Do you allow health promotion programs to be provided during company time (not lunch hour)?
YesNo