1 

Workplace Health in America Survey Instrument
2 

HEALTH INSURANCE 

HI1. In general, do you offer full, partial or no payment of premiums for personal health insurance for full-time 

employees?

Full insurance coverage offered

Partial insurance coverage offered

No insurance coverage offered

Don’t know

Refused

[If HI1 is NO, DK, REF, Skip to HI3]

HI2. Over the past 12 months, were full time employees asked to pay a larger proportion, smaller proportion or 

the same proportion of personal health insurance premiums compared to the previous 12 months (just 

premiums and not deductibles or co-pays)?

Larger

Smaller

About the same

Don’t know

Refused

HI3. Does your organization offer personal health insurance for your part-time employees?

Yes

No

Don’t know

Refused

HI4. Does your organization offer family coverage with your health insurance?

Yes

No

Don’t know

Refused

HEALTH RISK ASSESSMENTS

HRA1. In the past 12 months, were employees at this worksite location offered a health risk assessment or 

HRA? 

Yes

No

Don’t know

Refused [IF HRA1 is NO, DK, REF, skip to CP1]

HRA1.a. Who offered the HRA? 

The employer 

The health insurance plan 

A different third party vendor (i.e., not a health insurance provider) 

Don’t know

Refused
3 

HRA1.b. Approximately what percentage of employees completed the HRA? (Please feel free to provide an 

estimate, even if you are not sure of the true percentage.) 

1 – 25%

26 – 50%

51 – 75%

76 – 100%

Don’t know

Refused

HRA1.c. Were employees who completed the HRA: (Select all that apply)

Given their results

Given their results and provided feedback and education for identified health risks or conditions

Both

Neither of the above

Don’t know

Refused
4

PROMOTING HEALTH AT WORK

Does your worksite currently offer: Yes No Don’t 

know

Refused

CP1. Health education programs....which focus on skill development and 

lifestyle behavior change along with information dissemination and 

awareness building, preferably tailored to employees’ interests and 

needs? 

CP2. Supportive social and physical environment.....which includes an 

organization’s expectations regarding healthy behaviors, and 

implementation of policies that promote health and reduce risk of 

disease? For example: signage that promotes using the stairs, policies to 

restrict smoking, or increasing access to healthy foods at work.

CP3. Integration of the health promotion program into your 

organization’s structure which includes allocating dedicated resources, 

budget, and/or aligning with your business plan?

CP4. Linkage to related programs like employee assistance programs 

(EAPs) and programs to help employees balance work and family? 

CP5. Worksite health screening programs, ideally linked to medical care 

to ensure follow-up and appropriate treatment as necessary?

HISTORY OF HEALTH PROMOTION

Now we want to ask more detailed information about how HEALTH PROMOTION/WELLNESS PROGRAMS are 

organized at this worksite location. For the purpose of the next question, think VERY BROADLY about any 

educational materials, activities, classes, screenings, services, environmental supports, or policies that 

encourage employees to be healthy.

HP1. Thinking about this worksite location, did your organization offer any type of health promotion/wellness 

program for employees in the past 12 months?

Yes

No

Don’t know

Refused [If NO – skip to Work-Life questions WL1.]

HP2. How long has your health promotion/wellness program been in place? 

Less than 1 year

1 to 2 years

3 to 5 years

6 to 9 years

10 years or more

Don’t know

Refused
5

HP3. Is your health promotion/wellness program primarily managed by... (please choose one )

Staff employed by our organization

Staff employed by our health insurance provider 

Staff employed by a vendor/some other third party provider (not the health insurance provider)

Don’t know 

Refused

HP4. Is there at least one person who is assigned responsibility for the health promotion/wellness program 

offered at this worksite location?

Yes

No

Don’t know

Refused 

HP5. Does this worksite currently have a committee that addresses employee health promotion/wellness or 

safety? (Please choose one):

Yes, there is one committee, includes both health promotion/wellness and safety

Yes, there is one committee, includes health promotion/wellness but NOT safety

Yes, there is one committee, includes safety but NOT health promotion/wellness

Yes, there are two separate committees, one for health promotion/wellness and one for safety

NO, we have no committee addressing health promotion or safety 

Don’t know

Refused [IF NO, DK, REF, Skip to HP6.]

HP5.a. To what extent does this committee adequately represent a wide variety of workers (e.g., employees 

from different departments, shifts, and a wide array of health interests?)

1= not representative at all

2=somewhat representative

3=mostly representative

4=entirely representative

Don’t know

Refused

HP6. Does this organization include references to improving or maintaining employee health and/or safety in 

the business objectives or organizational mission statement?

Yes

No

Don’t know

Refused 
6

HP7. Thinking about your health promotion/wellness program at this 

worksite location overall, would you say it...

Yes No Don’t 

know

Refused

HP7.a. Has senior leadership visibly committed to employee health 

and safe work environments?

HP7.b. Has middle management visibly committed to employee 

health and safe work environments?

HP7.c. Has a champion(s) who is a strong advocate for the health 

promotion program?

HP7.d. Has an annual employee health promotion plan? [If HP7.d. is 

NO, DK, REF, skip to HP7.e.]

HP7.d.1 Does the plan include specific measurable goals and 

objectives to reach?

HP7.d.2 Does the plan include communication strategies that 

promote and market the program to employees to ensure high 

visibility of the program?

HP7.d.3 Does the plan include clear responsibility for who will 

implement each component of the plan?

HP7.e. Uses data to help decision-makers decide what to offer? [If

HP7.e. is NO, DK, REF, skip to HP7.f]

HP7.e.1. Do you use any type of organizational level assessment tool 

to benchmark changes, plan and/or evaluate health-related 

organizational level changes that you may make over time? (for 

example, CDC Worksite Health ScoreCard, HERO, Work Healthy 

America Tool)

HP7.f. Uses data to evaluate program success? [IF HP7.f is NO, DK, 

REF, skip to HP7.g.]

What types of data are used to evaluate program success?

HP7.f.1. Employee participation? 

HP7.f.2. Employee feedback about the program?

HP7.f.3. Employee morale or job satisfaction?

HP7.f.4. Changes in employee health risk behaviors?

HP7.f.5. Changes in employee disease rates or conditions?

HP7.f.6. Costs for employee health care claims?

HP7.f.7. Number or amount of worker compensation claims? 

HP7.f.8. Absenteeism?

HP7.f.9. Employee productivity or presenteeism?

HP7.f.10. Employee turnover?

HP7.f.11. Return on investment?
7

HP7.g. How much is available in dollars, annually, to spend on employee health promotion/wellness at this 

worksite location? [Note: It is fine to include salaries of employees who have responsibility for employee health 

as part of his/her job responsibility.]

No annual budget

Less than $1000

$1001 – $5000

$5001 – $10,000

$10,001 – $15,000

$15,001 – $20,000

$20,001 – $50,000

$50,001 – $100,000

$100,001 – $500,000

Over $500,000

Don’t know

Refused

[If they did not choose DK or Ref, ask HP8]

HP8. During the next 12 months (compared with the past 12 months), what do you expect that your 

organization’s financial investment will be in employee health promotion? (Please choose one.)

We will spend more

We will spend less

We will spend about the same amount

Don’t know

Refused
8

HEALTH PROMOTION PROGRAMS, HEALTH 

SCREENINGS, DISEASE MANAGEMENT

Next we will cover health education programs, environmental supports and policies and benefits related to 

specific health behaviors. Specifically, “programs” refer to any educational opportunity that seeks to improve 

knowledge, skills and/or change behaviors in ways that promote employee health or prevent disease using any 

of a variety of methods including print and online materials, contests, classes and/or other activities.

We will take one health behavior at a time and ask a series of questions about programs, then some specific 

strategies for environmental supports and policies/benefits that employers may offer.

HPR1 Physical Activity/Fitness/Sedentary Behavior 

HPR1.1. In the past 12 months, did you offer any programs to address physical activity/fitness/sedentary 

behavior for your employees?

Yes

No

Don’t know

Refused [If NO, DK, REF, skip to HPR1.2.a]

HPR1.1a. What TYPE of physical activity programs have you offered in the past 12 months? 

Awareness or Informational (e.g. this includes print or online materials, posters, flyers, brochures, educational 

materials, one-time presentations)

Skill-building – (e.g., this includes onsite, online classes or offsite classes in the community; one on one coaching; 

contests or competitions)

Both awareness/information and skill-building

Don’t know 

Refused

HPR1.1.b. Who typically offers these programs to employees?

Offered mostly by the employer

Offered mostly by the health plan

Offered mostly by a outsourced vendor, not the health plan

Offered mostly by combined efforts of employer, health plan, and/or vendor

Don’t know 

Refused

HPR1.1.c. Thinking about all physical activity/fitness/sedentary behavior programs that have been offered or 

sponsored here in the past 12 months, approximately what percentage of employees from this worksite 

location participate? (Please feel free to provide an estimate, even if you are not sure of the true percentage.)

1 – 25%

26 – 50%

51 – 75%

More than 75%

Don’t know

Refused 
9

In the past 12 months, did your worksite... Yes No Don’t 

know

Refused

HPR1.2.a. Provide an exercise facility onsite?

HPR1.2.b. Subsidize or discount the cost of onsite and/or 

offsite exercise facilities?

HPR1.2.c. Provide environmental supports for physical activity 

or recreation such as walking trails or tracks, maps of 

measured walking/jogging routes, bicycle racks, shower and 

changing room, open space for recreation, weight room?

HPR1.2.d. Post signs at elevators, stairwell entrances/exits and 

other key locations that encourage employees to use the 

stairs?

HPR1.2.e. Provide organized individual or group physical 

activity programs for employees (other than use of an exercise 

facility?) (e.g., walking or stretching , group exercise classes or 

weight training)

HPR1.2.f. Provide or subsidize physical fitness assessments, 

follow-up counseling, and exercise recommendations either 

onsite or through a community exercise facility?

HPR1.2.g. Provide free or subsidized lifestyle self-management 

programs that include advice on physical activity? 

HPR1.2.h. Provide a pedometer or FITBit or other physical 

activity tracking device for free or discounted rate to 

employees?

HPR1.2.i. Provide the option of using active work stations? 

(e.g. standing desk, treadmill desk, height adjustable 

workstation, pedal devices fitted underneath the desk) 

HPR1.2.j. Offer employees paid time to be physically active 

during work hours, including fitness breaks, walking meetings 

or other options?

HPR1.2.k. Encourage active transportation to and from work 

by providing things such as bike parking, shower access, pretax contributions for public transportation or providing parallel 

benefits to those who bike, walk or take transit to work as 

those who drive?

HPR2 Nutrition/Healthy Eating

HPR2.1. In the past 12 months, did you offer any programs to address nutrition and/or healthy eating for 

employees?

Yes

No

Don’t know

Refused [If NO, DK, REF, skip to HPR2.2.a]
10

HPR2.1.a. What TYPE of nutrition/healthy eating programs have you offered in the past 12 months? 

Awareness or Informational (e.g., this includes print or online materials, posters, flyers, brochures, educational 

materials, one-time presentations)

Skill-building – (e.g., this includes onsite, online classes or offsite classes in the community; one on one coaching; 

contests or competitions)

Both awareness/information and skill-building

Don’t know 

Refused

HPR2.1.b. Who typically offered these programs to employees?

Offered mostly by the employer

Offered mostly by the health plan

Offered mostly by a outsourced vendor, not the health plan

Offered mostly by combined efforts of employer, health plan, and/or vendor

Don’t know

Refused

HPR2.1.c. Thinking about all nutrition/healthy eating programs that have been offered or sponsored here in the 

past 12 months, approximately what percentage of employees from this worksite location participate?

(Please feel free to provide an estimate, even if you are not sure of the true percentage.)

1 – 25%

26 – 50%

51 – 75%

More than 75%

Don’t know

Refused

In the past 12 months, did your worksite... Yes No Don’t 

know

Refused

HPR2.2a. Provide employees with food preparation and storage 

facilities such as microwave oven, sink, refrigerator and/or 

kitchen?

HPR2.2.b. A written policy or formal communication which 

makes healthier food and beverages available during meetings 

when food is served?

HPR2.2.c. Offer or promote an onsite or nearby farmers’ market 

where fresh fruits and vegetables are sold?

HPR2.2.d. Provide free or subsidized lifestyle self-management 

programs that include advice or tools on healthy eating?

HPR2.3. Does your worksite location have... 

HPR2.3.a. A cafeteria or snack bar onsite?

HPR2.3.b. Vending machines that serve food?

HPR2.3.c. Vending machines that serve beverages?

HPR2.3.d. Food trucks that come to your worksite every day?

[IF YES to one of HPR2.3 a-d, ask HPR2.4.a. – e., otherwise skip to HPR3.1.]
11

HPR2.4. Does your worksite location... Yes No Don’t 

know

Refused

HPR2.4.a. Have a written policy or formal communication that 

makes healthier food and beverage choices available in 

cafeterias, vending, snack bars or food trucks? 

HPR2.4.b. Make most (more than 50%) of the food and beverage 

choices available in cafeterias/snack bars, vending, catering 

trucks be healthy food items? 

HPR2.4.c. Provide nutritional information (beyond standard info 

on labels) on sodium, calories, trans-fats, or saturated fats for 

foods and beverages sold in worksite cafeterias, snack bars, 

vending or food trucks?

HPR2.4.d. Identify healthier food and beverage choices with 

signs or symbols? 

HPR2.4.e. Subsidize or provide discounts on healthier foods and 

beverages offered in vending machines, cafeterias, snack bars or 

food trucks?

HPR3 Obesity/Weight Management

HPR3.1. In the past 12 months, did you offer any programs to address obesity/weight management for 

employees?

Yes

No

Don’t know

Refused [If NO, DK, REF to HPR3.1. then SKIP to HPR3.2.]

HPR3.1.a. What TYPE of obesity/weight management programs have you offered in the past 12 months? 

Awareness or Informational (e.g., this includes print or online materials, posters, flyers, brochures, educational 

materials, one-time presentations)

Skill-building – (e.g., this includes onsite, online classes or offsite classes in the community; one on one coaching; 

contests or competitions)

Both awareness/information and skill-building

Don’t know 

Refused

HPR3.1.b. Who typically offered these programs to employees?

Offered mostly by the employer

Offered mostly by the health plan

Offered mostly by a outsourced vendor, not the health plan

Offered mostly by combined efforts of employer, health plan, and/or vendor

Don’t know

Refused
12

HPR3.1.c. Thinking about all obesity/weight management programs that have been offered or sponsored here 

in the past 12 months, approximately what percentage of employees from this worksite location participate?

(Please feel free to provide an estimate, even if you are not sure of the true percentage.)

1 – 25%

26 – 50%

51 – 75%

More than 75%

Don’t know

Refused

HPR3.2. In the past 12 months, did your worksite provide full or partial coverage for bariatric surgery (i.e., 

weight loss surgery), such as gastric bypass?

Yes

No

Don’t know

Refused 

HPR4 Tobacco Use 

HPR4.1. In the past 12 months, did you offer any programs to help employees stop using tobacco products?

Yes

No

Don’t know

Refused [If NO, DK, REF to HPR4.1 then SKIP to HPR4.2.a]

HPR4.1.a. What TYPE of tobacco use programs have you offered in the past 12 months? 

Awareness or Informational (e.g., this includes print or online materials, posters, flyers, brochures, educational 

materials, one-time presentations)

Skill-building – (e.g., this includes onsite, online classes or offsite classes in the community; one on one coaching; 

contests or competitions)

Both awareness/information and skill-building

Don’t know 

Refused

HPR4.1.b. Who typically offered these programs to employees?

Offered mostly by the employer

Offered mostly by the health plan

Offered mostly by a outsourced vendor, not the health plan

Offered mostly by combined efforts of employer, health plan, and/or vendor

Don’t know

Refused
13

HPR4.1.c. Thinking about all tobacco use programs that have been offered or sponsored here in the past 12 

months, approximately what percentage of employees from this worksite location participate? (Please feel free 

to provide an estimate, even if you are not sure of the true percentage.)

1 – 25%

26 – 50%

51 – 75%

More than 75%

Don’t know

Refused

In the past 12 months, did your worksite... Yes No Don’t 

know

Refused

HPR4.2.a. Refer tobacco users to a state or other tobacco 

cessation telephone quit line?

HPR4.2.b. Provide or cover free or subsidized tobacco cessation 

counseling (including individual, group, and telephone 

counseling)?

HPR4.2.c. Provide health insurance coverage with no or low outof-pocket costs for FDA-approved over-the-counter and/or 

prescription tobacco cessation medications including nicotine 

replacement?

HPR4.2.d. Inform employees about health insurance coverage or 

programs that include tobacco cessation medication and 

counseling?

HPR4.2.e. Help remove barriers to accessing tobacco cessation 

treatments, such as copayments, requirements for prior 

authorization, and limitations on the number and duration of 

treatments?

HPR4.2.f. Display signs (including ‘no smoking’ signs)?

HPR4.2.g. Have a written policy to restrict smoking? [if NO, DK, 

REF, skip to HPR.5.1.]

In the past 12 months, did you offer any of the following specific 

strategies for eliminating use of tobacco products or minimizing 

exposure to secondhand smoke at work? 

Yes No Don’t 

know

Refused/ 

Does not 

apply

HPR4.2.g.1. Does the written policy ban all tobacco use at your 

worksite?

HPR4.2.g.2. Does the written policy ban use of smokeless tobacco, 

e-cigarettes and other tobacco products? 

HPR4.2.g.3. Actively enforce a written policy banning tobacco use? 

HPR4.2.g.4. Have a policy that does not allow use of tobacco 

products in company vehicles? (Include option for Does not apply)

HPR4.2.g.5. Prohibit sale of tobacco products on company 

property (for example, your worksite does not sell tobacco 

products on company property in vending machines or through 

onsite vendors)? 
14

HPR4.2.g.6. Which of these best describes your smoking policy for INDOOR PUBLIC OR 

COMMON AREAS, such as lobbies, rest rooms, and lunch rooms?

Not allowed in ANY public areas

Allowed in some public areas

Allowed in ALL public areas

Not applicable

Don’t know

Refused

HPR4.2.g.7. Which of these best describes your smoking policy for WORK AREAS?

Not allowed in ANY work areas

Allowed in some work areas

Allowed in ALL work areas

Not applicable

Don’t know

Refused

HP5 Excessive Alcohol Use/Drug Abuse

HPR5.1. In the past 12 months, did you offer any programs to address excessive alcohol use and/or drug abuse?

Yes

No

Don’t know

Refused [If NO, DK, REF to HPR5.1. then SKIP to HPR6.1.]

HPR5.1.a. What TYPE of excessive alcohol use/drug abuse programs have you offered in the past 12 months? 

Awareness or Informational (e.g., this includes print or online materials, posters, flyers, brochures, educational 

materials, one-time presentations)

Skill-building – (e.g., this includes onsite, online classes or offsite classes in the community; one on one coaching; 

contests or competitions)

Both awareness/information and skill-building

Don’t know 

Refused

HPR5.1.b. Who typically offered these programs to employees?

Offered mostly by the employer

Offered mostly by the health plan

Offered mostly by a outsourced vendor, not the health plan

Offered mostly by combined efforts of employer, health plan, and/or vendor

Don’t know

Refused
15

HPR6 Lactation Support

HPR6.1. In the past 12 months, did you offer any lactation support programs for employees?

Yes

No

Don’t know

Refused [If NO, DK, REF to HPR6.1. then SKIP to HPR7.1.]

HPR6.1.a. What TYPE of lactation support programs have you offered in the past 12 months? 

Awareness or Informational (e.g., this includes print or online materials, posters, flyers, brochures, educational 

materials, one-time presentations)

Skill-building – (e.g., this includes onsite, online classes or offsite classes in the community; one on one coaching; 

contests or competitions)

Both awareness/information and skill-building

Don’t know 

Refused

HPR6.1.b. Who typically offered these programs to employees?

Offered mostly by the employer

Offered mostly by the health plan

Offered mostly by a outsourced vendor, not the health plan

Offered mostly by combined efforts of employer, health plan, and/or vendor

Don’t know

Refused

HPR6.1.c. Thinking about all support programs for breastfeeding or pregnant employees that have been offered 

or sponsored here in the past 12 months, approximately what percentage of employees from this worksite 

location participate? (Please feel free to provide an estimate, even if you are not sure of the true percentage.)

1 – 25%

26 – 50%

51 – 75%

More than 75%

Don’t know

Refused

HPR7 Musculoskeletal Disorders/Arthritis/Back Pain

HPR7.1. In the past 12 months, did you offer any programs to educate about prevention of musculoskeletal 

disorders, arthritis or back pain?

Yes

No

Don’t know

Refused [If NO, DK, REF to HPR7.1. then SKIP to HPR8.1.]
16

HPR7.1.a. What TYPE of musculoskeletal disorder, arthritis, or back pain programs have you offered in the past 

12 months? 

Awareness or Informational (e.g., this includes print or online materials, posters, flyers, brochures, educational 

materials, one-time presentations)

Skill-building – (e.g., this includes onsite, online classes or offsite classes in the community; one on one coaching; 

contests or competitions)

Both awareness/information and skill-building

Don’t know 

Refused

HPR7.1.b. Who typically offered these programs to employees?

Offered mostly by the employer

Offered mostly by the health plan

Offered mostly by a outsourced vendor, not the health plan

Offered mostly by combined efforts of employer, health plan, and/or vendor

Don’t know

Refused

HPR7.1.c. Thinking about all musculoskeletal disease, arthritis or back pain programs that have been offered or 

sponsored here in the past 12 months, approximately what percentage of employees from this worksite 

location participate? (Please feel free to provide an estimate, even if you are not sure of the true percentage.)

1 – 25%

26 – 50%

51 – 75%

More than 75%

Don’t know

Refused

HPR8 Stress Management

HPR8.1. In the past 12 months, did you offer any programs to address stress management for employees?

Yes

No

Don’t know

Refused [If NO, DK, REF to HPR8.1. then SKIP to HPR9.1.]

HPR8.1.a. What TYPE of stress management programs have you offered in the past 12 months? 

Awareness or Informational (e.g., this includes print or online materials, posters, flyers, brochures, educational 

materials, one-time presentations)

Skill-building – (e.g., this includes onsite, online classes or offsite classes in the community; one on one coaching; 

contests or competitions)

Both awareness/information and skill-building

Don’t know 

Refused
17

HPR8.1.b. Who typically offered these programs to employees?

Offered mostly by the employer

Offered mostly by the health plan

Offered mostly by a outsourced vendor, not the health plan

Offered mostly by combined efforts of employer, health plan and/or vendor

Don’t know

Refused

HPR8.1.c. Thinking about all stress management programs that have been offered or sponsored here in the past 

12 months, approximately what percentage of employees from this worksite location participate? (Please feel 

free to provide an estimate, even if you are not sure of the true percentage.)

1 – 25%

26 – 50%

51 – 75%

More than 75%

Don’t know

Refused

HPR9 Sleep

HPR9.1. In the past 12 months, did you offer any programs to promote healthy sleep and reduce fatigue for 

employees?

Yes

No

Don’t know

Refused [If NO, DK, REF to HPR9.1. then SKIP to HS1.1.]

HPR9.1.a. What TYPE of healthy sleep programs have you offered in the past 12 months? 

Awareness or Informational (e.g., this includes print or online materials, posters, flyers, brochures, educational 

materials, one-time presentations)

Skill-building – (e.g., this includes onsite, online classes or offsite classes in the community; one on one coaching; 

contests or competitions)

Both awareness/information and skill-building

Don’t know 

Refused

HPR9.1.b. Who typically offered these programs to employees?

Offered mostly by the employer

Offered mostly by the health plan

Offered mostly by a outsourced vendor, not the health plan

Offered mostly by combined efforts of employer, health plan, and/or vendor

Don’t know

Refused
18

HPR9.1.c. Thinking about all the healthy sleep programs that have been offered or sponsored here in the past 

12 months, approximately what percentage of employees from this worksite location participate? (Please feel 

free to provide an estimate, even if you are not sure of the true percentage.)

1 – 25%

26 – 50%

51 – 75%

More than 75%

Don’t know

Refused

HEALTH SCREENINGS

Now let’s talk about health screening tests that may be offered to employees at this worksite location. Health 

screenings are offered to employees to help detect health problems to get employees referred for proper 

treatment.

In the past 12 months, were any of the following 

screenings made available to your employees?

a.

Screened 

(Y/N/DK/REF)

[If Screened is 

YES, answer

question in 

column b.]

b.

Are high risk 

employees 

referred to 

health 

professional 

for treatment

and provided 

follow-up 

education? 

(Y/N/DK/REF)

HS1.1. Blood pressure [If NO to HS1.1.a., skip to 

HS1.2.]

HS1.1.1. Were blood pressure monitoring devices 

available with instructions for employees to 

conduct their own self assessments?

HS1.2. Blood cholesterol.

HS1.3. Diabetes or prediabetes.

HS1.4. Obesity (e.g., body composition 

measurement, such as height and weight, BMI 

scores, or body fat assessments [not self-report]).

HS1.5. Breast cancer using mammography.

HS1.6. Colorectal cancer using a colonoscopy or a 

kit to measure blood in the stool.

HS1.7. Cervical cancer using a PAP test or test for 

human papillomavirus (HPV).

HS1.8. Depression.

HS1.9. Arthritis or other musculoskeletal problems.
19

HS2.a. Thinking about all of the screenings offered to employees at this worksite, were they usually offered to 

employees... 

Onsite

Offsite 

Both

Don’t know

Refused

HS2.b. Think about all of the health screenings offered to employees at this worksite. Would you estimate the 

usual employee participation as: 

1 – 25%

26 – 50%

51 – 75%

More than 75%

Don’t know

HS3. During the past 12 months, were flu shots made available to your employees?

Yes, onsite

Yes, offsite

Yes, onsite and offsite

No

Don’t know

Refused
20

DISEASE OR RISK MANAGEMENT

Disease or risk management information or programs: These programs are offered for employees who 

already have a particular disease or health condition and can include specific information, education,

and/or services to better manage the condition. These programs may be offered to employees either 

through your health plan, a third-party vendor, or directly by the employer.

Select all that apply

Nothing

offered 

for this 

topic

Don’t Know/

Refused

During the past 12 months, 

were any disease or risk 

management information 

or programs related to the 

following topics made 

available to your 

employees? (please include 

programs provided by the 

employer, health plan or 

third party vendor)

Information, 

such as 

brochures, 

videos, 

posters, 

pamphlets, 

newsletters

Educational 

seminars, 

workshops, 

or classes on 

preventing 

and 

controlling 

the condition

One-onone 

counseling

/coaching 

and followup 

monitoring

DM1.1. Asthma 

DM1.2. Cardiovascular 

disease 

DM1.3. Cancer or cancer 

survivorship 

DM1.4. Diabetes or prediabetes

DM1.5. Depression

DM1.6. High risk 

pregnancy 

DM1.7. Hypertension or 

high blood pressure

DM1.8. High blood 

cholesterol

DM1.9. Obesity 

DM1.10. 

Migraine/headache 

DM2.a. Thinking about all of the disease management programs offered to employees at this worksite, were 

they usually offered... 

Onsite in-person

By phone counseling

Online program

Multiple ways

Don’t know

Refused
21

DM2.b. Did your organization provide any training for managers/supervisors about disease management 

topics? (e.g., training on how to recognize the disease, productivity/safety issues, and/or company/community 

resources for managing this disease?) 

Yes

No

Don’t know

Refused

DM3. During the past 12 months, have you had an onsite health clinic available for employees at this worksite 

location?

Yes

No

Don’t know

Refused

INCENTIVES

Next we will ask about incentives you may offer to employees. In this section, you can think of incentives 

broadly – including incentives that are used to reward participation or behavior change, or, penalize employees 

for not improving health behaviors. 

KP2. During the past 12 months, have you offered any incentives related to the health promotion/wellness 

programs you have offered to your employees?

Yes, we have offered incentives

No, we have not offered incentives, but we plan to in the next 12 months

No, we have not offered incentives and have no plans to offer them in the next 12 months

Don’t know

Refused [IF NO, DK, REF – Skip to WL1.]

KP3. How did you use any type of incentive supporting your 

employee health promotion/wellness program in the past 12 

months? Did you offer incentives that were... 

Yes No Don’t 

know

Refused

KP3.1. Tied primarily to participation or attendance in a health 

programs?

KP3.2. Tied primarily achieving a particular health standard?

KP3.3. Tied to both participation and achieving a health 

standard?

[IF YES TO ANY KP3. Ask KP4.

If NO to ALL KP3, skip to KP5]. 
22

KP4. We understand that many factors influence whether employees achieve certain health goals, but if you 

were to focus solely on the use of incentives, how effective were the incentives you offered for achieving their 

intended outcome?

Not at all effective

Somewhat effective

Effective

Extremely effective

Don’t know

Refused

KP5. What type of incentives did you use in the past 12 months 

at this worksite location?

Yes No Don’t 

know

Refused

KP5.a. Premium discounts.

KP5.b. Copay differences.

KP5.d. Cash rewards.

KP5.e. Add money to flexible spending accounts.

KP5.f. Additional paid time off.

KP5.g. Gifts or prizes.

KP5.h. Other (Please specify _____________________________).
23

WORK-LIFE PROGRAMMING, POLICIES AND 

BENEFITS

WL1. During the last 12 months, did this organization or your health plan offer an employee assistance program 

(EAP) to employees and/or their families?

Yes, for employees

Yes, for employees and their families

No

Don’t know

Refused 

WL2. During the past 12 months, did your worksite provide training to prevent bullying or violence in the 

workplace? 

Yes

No

Don’t know

Refused

WL3. During the past 12 months, did this worksite location provide employees with any of the following: 

(Select all that apply)

Paid sick hours or days

Paid personal hours or days

Paid vacation hours or days 

None

Other (please specify)______________ 

Don’t know

Refused

During the past 12 months, did this worksite location... Yes No Don’t 

know

Refused

WL4. Offer employees flexible work schedules (Note: flexible 

schedules can include allowing employees to choose their own 

starting and quitting times within a range of hours, working 

compressed work weeks, teleworking, and job sharing)? 

WL5. Allow employees to work from home?

WL6. Offer disability leave or disability insurance?

WL7. Offer paid family leave for new parents? (Note, this 

includes paternity, maternity and adoption leaves)

WL8. Allow employees to take unpaid parental leave?

WL9. Help employees cover any costs of child care for their 

children by directly reimbursing for costs or by providing a 

flexible spending account?

WL10. Offer onsite or offsite child care for employees?

WL11. Help employees cover any costs of eldercare?

WL12. Offer onsite or offsite eldercare for employees?
24

PROGRAM BARRIERS

B1. Thinking across all types of employee health 

promotion/wellness programs, please rate the 

following on the extent to which each has been

a barrier or challenge to this worksite in offering 

these programs? 

1=Not at all challenging to 5= Extremely challenging

1-Not at all 

Challenging

2-Slightly 

Challenging

3-Somewhat 

Challenging

4-

Challenging

5-Extremely 

Challenging

Don’t 

know

Refused

B1.1. Lack of employee interest.

B1.2. Employee distrust of employer-sponsored 

programs.

B1.3. Cost (e.g., lack of funds).

B1.4. Lack of trained and experienced staff.

B1.5. Conflicting or competing business 

demands.

B1.6. Concern about confidentiality/privacy.

B1.7. Demonstrating program results.

B1.8. Lack of qualified vendors.

B1.9. Lack of senior management support.

B1.10. Lack of middle management or 

supervisor support.

B1.11. Changes in the regulatory 

environment/legal concerns (e.g., HIPAA, ADA).

B1.12. Lack of physical space at work.

OCCUPATIONAL SAFETY AND HEALTH

The next questions will ask about safety-related programs at this worksite location.

OSH1. Is there at least one dedicated person who is responsible for the safety of employees at this worksite 

location?

Yes

No

Don’t know

Refused [If NO, DK, REF – skip to OSH3]

OSH2. Does the person who is responsible for employee safety also have responsibility for promoting 

health/wellness at this worksite location?

Yes

No

Don’t know

Refused
25

Does this worksite... Yes No Don’t 

know

Refused

OSH3. Have a written injury and illness prevention program? 

OSH4. Have a policy requiring or encouraging the reporting of 

worksite injuries and near misses, and illnesses? 

OSH5. Provide opportunities for employee input on hazards and 

solutions to reduce or eliminate those hazards? 

OSH6. Provide new employees with formal training on how to 

avoid on-the-job accidents, injuries, and illnesses?

Are these present at your worksite location? Yes No Don’t 

know

Refused

OSH7.1. Efforts to protect and promote worker health include

changes to improve work design and the work environment, 

along with educating individual workers. 

OSH7.2.Employees and management work together to set 

priorities, plan, implement and evaluate both safety and health 

promotion programs. 

OSH7.3. Decision making about policies, programs and practices 

related to worker health is coordinated across departments, 

including those responsible for occupational safety and health 

and those responsible for health promotion. 

EMERGING ISSUES

E1. What training or technical assistance topics would be most useful for the people responsible for promoting 

employee health/wellness and safety at your worksite? (check all that apply)

Best practices for employee safety and health promotion.

Conducting health and safety risk assessments.

Documenting health improvements and cost impacts of wellness and safety programs.

Laws, regulations, policies, and standards related to workplace health and safety programs.

Health care insurance, coverage, workers compensation, and claims processes.

Partnership building, integration, coordination and collaboration.

Leadership and management engagement (communication, marketing and advocacy).

Program planning, implementation and evaluation skills.

Other (please specify)__________________________________________.

E2. To what extent do you believe that employees work within a “culture of health” at this worksite location? 

(Note: a workplace culture of health is one in which leadership creates a work environment that values and 

supports employee health and provides healthy work conditions as the normal way of doing business.)

 |------------|------------|------------|------------|------------|------------|------------|------------|------------|

 1 2 3 4 5 6 7 8 9 10

Not at all Completely
26

WORKFORCE DEMOGRAPHICS

For each question below, please estimate the percentage using 0 – 100%. Please estimate if you do not have 

precise percentages.

Considering ALL (full and part-time) employees at this worksite 

location, what percentage...

Percentage Don’t 

know

Refused

WD1.1 Are younger than age 30?

WD1.2 Are age 60 years or older?

WD2. Are female?

WD3. Are hourly/non-exempt workers?

WD4. Work something OTHER THAN a typical daytime shift (e.g., 

9a.m.—5p.m., 7a.m.—3p.m.) or during normal business hours? 

WD5. Regularly work remotely or offsite?

WD6. Are under collective bargaining or unionized?

WD7. What is the average annual percentage of turnover at this 

worksite location?
27

Supplemental Survey Items

The following section is optional, but please answer these questions to provide a little more information about 

specific things your worksite may be providing to employees.

In the past 12 months, did your worksite... Yes No Don’t 

know

Refused

SUP1. Participate in a community coalition that is addressing 

excessive alcohol use, drug abuse, or both?*

SUP2. Offer excessive alcohol use or drug abuse support 

programs?*

SUP3. Provide a formal, written policy for addressing employee 

use of alcohol at the worksite/on the job?*

SUP4. Provide a formal, written policy addressing employee use 

of drugs at the worksite/on the job?*

SUP5. Provide a formal, written policy addressing employee use 

of medical marijuana at the worksite/on the job?*

[if they have an EAP] SUP6. Offer screening, referrals and/or 

brief interventions for excessive alcohol use through your EAP?

[if they have an EAP] SUP7. Offer screening and referrals to 

specialized treatment programs for alcohol dependence through

your EAP?

[if they have an EAP] SUP8. Offer screening, referrals and/or 

brief interventions for substance abuse through your EAP?

[if they have an EAP] SUP9. Offer screening, referrals and/or 

brief interventions for stress, anxiety and/or depression through

your EAP?

[if they have an EAP] SUP10. Offer screening, referrals and/or 

brief interventions to identify, prevent and/or treat domestic 

violence through your EAP?

SUP11. Provide training for workers about the importance of 

getting sufficient sleep for their safety, health, and well-being 

both on and off the job?*

SUP12. Provide training for workers to help them cope with shift 

work and long work hours?*

SUP13. Provide training for managers on the safety and health 

risks associated with employee fatigue and poor sleep?*

SUP14. Provide training for managers to improve the 

organization of work so as to reduce employee risk for poor 

sleep and fatigue?*

SUP15. Improve design of work schedules, including policies for 

the number of consecutive days or hours allowed to be worked, 

or the type of shifts in place?*

SUP16. Offer breaks during the work shift or work day?*

SUP17. Have dedicated space that is quiet where employees can 

engage in relaxation activities, such as meditation, yoga, prayer,

or naps?*
28

SUP18. Organize social events throughout the year (e.g.,

worksite sponsors or organizes team building events, company 

picnics or employee sports teams)?*

SUP19. Provide training for managers on identifying and 

reducing stress-related issues (e.g., training on conducting 

equitable performance reviews, communication, personnel 

management, assertiveness, time management, job redesign, or 

conflict resolution)?*

SUP20. Provide opportunities for employee to participate in 

organizational decisions (e.g., procedures, scheduling, and 

workload) that affect job stress?*

SUP21. Provide safe places and/or opportunities that encourage 

social connectedness for employees at work (e.g., places that 

allow people to interact and build supportive relationships and 

meaningful connections)?*

SUP22. Provide training for managers and workers on identifying 

or recognizing work conditions that might increase risk of 

musculoskeletal disease, arthritis, or back pain?*

SUP23. Provide intervention strategies for controlling ergonomic 

hazards with engineering or administrative controls?*

SUP24. Provide ergonomic assessments and reasonable 

accommodations?*

SUP25. Educate employees about worker compensation and 

disability benefits?*

SUP26. Provide policies to ensure that employees return to work 

safely and avoid re-injury?*

SUP27. Have a written policy on breastfeeding for employees?*

SUP28. Provide a private space (other than a restroom) that may 

be used by an employee to pump breast milk?*

SUP29. Provide access to a breast pump at the worksite?*

SUP30. Provide flexible times to allow mothers to pump breast 

milk at this worksite location?*

SUP31. Provide free or subsidized breastfeeding support groups 

or educational classes?*

*

These items will only be asked of respondents who indicated in question HP1 that they have a health promotion 

program.
29

Does this worksite location... Yes No Don’t 

know

Refused

SUP32. Have senior leadership who demonstrates commitment 

to 2both safe work design and worker well-being?

SUP33. Plan initiatives that jointly protect worker health, safety 

and well-being?

SUP34. Have efforts to protect and promote worker health that 

include training of supervisors?

SUP35. Have communication and programming that protects 

worker health is included with efforts to promote employee 

well-being?

SUP36. Employ individuals who work outdoors? [If NO, DK, REF, 

skip to SUP]

Does this worksite offer any of the following that relate to sun 

protection/skin cancer prevention?

SUP37. Educational information about sun protection to workers 

through instruction, posters, or brochures?

SUP38. Environmental approaches to encourage sun protection 

(e.g., provide sunscreen or shade)?

SUP39. Policies to support sun protection practices (e.g., require 

sun protective behavior)?

We have a few questions about the groups or organizations you may typically partner with to offer employee 

health promotion/wellness programs. 

During the past 12 months, did you partner with any of the 

following to offer health programs for your employees?

Yes No Don’t 

know

Refused

SUP40. State/local public health department.

SUP41. Workers compensation provider.

SUP42. Health related organization (e.g. Am Heart Association, 

Am Cancer Society).

SUP43. Hospital.

SUP44.Community organization like the YMCA or YWCA.

SUP45. Business group (Wellness Council, Chamber of Commerce 

or other business group).

SUP46. Other (please specify)_________________________.