Employee Needs Assessment Survey

1. Which of the following health concerns would you like to know more about? (Circle all that apply.)



1. Foods that keep you healthy
2. Physical activity and exercise (enjoyable ways to keep fit)
3. Effective ways to manage stress
4. Strategies for total health improvement
5. Weight management
6. Help with smoking or tobacco use
7. Cancer prevention
8. Diabetes prevention or management
9. Heart disease prevention or management
10. Blood pressure
11. Blood cholesterol
12. Heart attacks/strokes
13. CPR
14. Self-care


2. From which of the following sources do you currently get most of your health information? (Circle up to three sources.)



1. Television, radio
2. Newspapers, magazines
3. Reference books
4. The Internet
5. Doctors
6. Other health professionals
7. Voluntary health organizations
8. Health promotion programs at work
9. Friends, family and other sources


3. There are many ways to get health information at the worksite. Which of the following ways would you prefer? (Circle all that apply.)



1. Pamphlets and other written materials
2. Films and videos
3. Internet resources
4. Health screenings
5. Personalized health counseling
6. Talks by experts (seminars)
7. Discussion groups
8. Classes and courses
9. Contests and incentive programs
10. Employee Assistance Programs


4. How long should a health promotion activity or counseling session last? (Circle only one answer.)



1. Less than 30 minutes
   
2. 30-45 minutes
3. 45-60 minutes


5. What time of day would be best for you to participate in a health promotion activity? (Circle only one answer.)



1. Before work
2. Lunch hour
3. After work
4. Would not participate
5. Other


6. In which of the following support groups would you be likely to participate? (Circle all that apply.)



1. Walking group
2. Weight control group
3. Parenting group
4. Other _____________________


7. Below are health screening tests which could be offered to employees on a confidential basis. Please circle all those in which you have an interest and would likely participate.



1. Blood pressure
2. Blood cholesterol
3. Blood glucose (sugar)
4. Colon/rectal cancer
5. Skin cancer
6. Breast cancer
7. Male cancers
8. Body fat
9. Glaucoma
10. Fitness assessments (cardiovascular fitness, flexibility, strength)
11. Hearing
12. Oral health


8. Circle all the activities in which you would be likely to participate.



1. Pick up educational materials on health topics
2. Receive personalized health counseling at work
3. Check out a health/fitness video to watch at home
4. Use a guide to Internet resources
5. Participate in a challenge or incentive program as an individual
6. Participate in a challenge or incentive program on a team
7. Read a health and fitness newsletter
8. Share health information with family members
9. Invite family members to participate in worksite health promotion activities
10. Help plan and promote health promotion activities at work
11. Attend a health promotion seminar or talk (single session)
12. Attend a health promotion course (multiple sessions)


9. Would you be willing to cost-share with the company for some health promotion activities? (Circle only one answer.)



1. Not interested in any health promotion activities
2. Interested, but unwilling to contribute to cost
3. Interested, and willing to contribute a reasonable amount


10. What is your gender?



1. Male
2. Female


11. What is your current job category?



1. Salaried (management)
2. Salaried (other)
3. Hourly


12. What is your age (at last birthday)? __________ years



13. Please give any suggestions or recommendations for specific activities to include in the health promotion program.





14. Are there aspects of our work environment that should be changed to be more supportive of healthy lifestyles among our employees? If yes, please explain.





15. If the company decided to offer incentives to promote participation in health promotion programs and healthy behaviors, what kind of incentive would prompt you to make healthy behavior changes?