Workplaces often use a survey form to determine interest in the various aspects of a workplace health and wellness program. The following is a sample. Be sure to customize it for your needs at your workplace. See the OSH Answers on "Workplace Health and Wellness Program - Getting Started" for more information on programs in general.

Sample Workplace Health and Wellness Survey

ABC Company is looking into the need for a workplace health and wellness program. We are interested in learning more about your opinions and interests. Your answers will be used to help plan the program and to decide which types of programs to offer.

• Senior management has agreed to let everyone take a few minutes to complete this survey.
• Please do not put your name on the form because we would like to keep this survey confidential.
• Please return the forms by putting them in a sealed envelope and placing them in the inter-office mail.

1. Sex:

      Male      Female

2. Age Group:

      under 21      21 - 30      31 - 40      

      41 - 50       51 - 60      Over 60

3. Do you have any health concerns about yourself, your family, or something arising from the workplace?

4. Would you like ABC Company to help with these concerns?

      Yes      No      Not sure

Explain your answer

5. Indicate how you feel about the following statements:

6. Which of the following activities would you prefer to participate in? (Check all that you would be likely to join)

7. When would you be able to participate?

8. Where would you prefer to attend a program?

    Work

    Private health club

    Local School or Facility/Hall

    Other

9. If necessary, would you be willing to share in the cost of a program?    Yes     No

10. Do you have any additional comments or concerns you would like the committee to know?