CDC Work@Health Employer Application Form

Form Approved

OMB No. 0920-XXXX

Exp. Date XX-XX-XXXX

CDC Work@Health^TM Employer Application Form

Public reporting of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a current valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Respondents / Sources	Method	Content	Timing	Respondents	Time per Respondent
Employer Representative (or trainee) – all interested worksites	Work@HealthTM Employer Application Form (conducted online)	Contact information Employer characteristics Status of worksite health program	Prior to training	600	0.33 hrs

This is an online form for employers who are interested in participating in the Work@Health^TM Program. This form will be available in December 2013 for interested individuals to share their contact information and apply to participate in the Work@Health^TM program.

Introduction

Informed Consent

We’d like to give you some more information to help you decide whether or not you would like to participate.

• This project is funded by the Centers for Disease Control and Prevention (CDC). Many parts of this project are being managed by the ASHLIN Management Group (ASHLIN). ASHLIN is a private sector consulting firm with a focus in the area of health and human services and is based in Greenbelt, MD. They are helping CDC implement the Work@Health^TM Program. The Public Health Management Corporation (PHMC), a non-profit, public health institute located in Philadelphia, PA and part of the ASHLIN Team, designed this form.

• You are being asked to share your contact information so that we can communicate with you about the Work@Health^TM Program.

• Your participation is voluntary, and you may skip any questions you do not want to answer. You may also choose to stop filling out the form at any time.

• This form is designed to take approximately 20 minutes to complete.

• All responses you provide will be maintained in a secure manner. We will not disclose your responses or anything about you unless we are compelled by law. Your responses will be combined with other information we receive and reported in aggregate as feedback from all respondents. In our project reports, your name will not be linked to the information or comments you provide.

• There are no risks or benefits to you personally for completing this form.

• CDC is authorized to collect information for this project under the Public Health Services Act.

• If you have any questions, you can contact Kristin Minot. Her telephone number is 215-985-2519 and her email is Kristin@phmc.org.

Employer Training Registration Form

The information that we are asking you to provide below will help us to communicate with you about Work@Health^TM. It will also help us to select employers for the training that represent different sizes, locations, industry types, and experiences in worksite health.

Employer Name: _______________________________________________

Primary Location:

Employer Zip-Code: ___ ___ ___ ___ ___ -- ___ ___ ___ ___

Mailing Address 1: _________________________________________

Mailing Address 2: _________________________________________

Mailing City: _________________________________________

Mailing County: _________________________________________

Mailing Zip Postal: ___ ___ ___ ___ ___ -- ___ ___ ___ ___

Location Designation:  Rural  Urban  Suburban

Primary Contact Person:

Title: _______________________________________

Name: _______________________________________

Primary Phone: _______________________________________

Contact text message phone number: _______________________

Primary email address: _____________________________

Confirm email address: _____________________________

Please select method to receive notifications:

 Email  Phone  Text Message

Secondary Contact Person:

Title: _______________________________________

Name: _______________________________________

Primary Phone: _______________________________________

Contact text message phone number: _______________________

Primary email address: _____________________________

Confirm email address: _____________________________

Please select method to receive notifications:

 Email  Phone  Text Message

Employer Information:

What industry best describes your primary business activity?

• Agriculture, Forestry, Fishing and Hunting

• Mining, Quarrying, and Oil and Gas Extraction

• Utilities

• Construction

• Manufacturing

• Wholesale Trade

• Retail Trade

• Transportation and Warehousing

• Information

• Finance and Insurance

• Real Estate and Rental and Leasing

• Professional, Scientific, and Technical Services

• Management of Companies and Enterprises

• Administrative and Support and Waste Management and Remediation Services

• Educational Services

• Health Care and Social Assistance

• Arts, Entertainment, and Recreation

• Accommodation and Food Services

• Public Administration

• Other Services (specify) _________________________

Number of Employees (full and part time): ____________________

Internet Accessibility (for staff participating in Work@Health^TM training)?

 Yes  No

Type of Employer: [drop down]

 Private Sector  Local Gov’t  State Gov’t

 Federal Gov’t  Non-Profit Education [K-12]  Education [Higher Ed]

Has your organization been in operation since February 1, 2012?

___ Yes ___ No ___ Not sure

Is your organization based (headquartered) in the United States?

___ Yes ___ No

Employer website: ____________________________________________________

Special Characteristics:

Virtual Work Environment/No office location  Yes  No

Minority Owned  Yes  No

Women Owned  Yes  No

Veteran Owned  Yes  No

The following questions are about health benefits and the current status of your worksite health program.

1. Which of the following statements best describes your health insurance benefits:

   1. We do not offer health insurance to our employees

   2. We offer health insurance, but we do not contribute a percentage of the premium.

   3. We offer health insurance and employees share the cost.

   4. We offer health insurance to our employees and we pay for it completely.

2. With respect to addressing employee health issues at your worksite, how ready is your organization to take action?

   1. Not at all ready (not seriously thinking about making a change, unaware that employee health is or may be an issue)

   2. Not quite ready (thinking about employee health issues, weighing the pros and cons of taking action, but not ready to take action)

   3. Somewhat ready (committed to taking action but researching options and/or gathering information on what to do)

   4. Almost ready (active preparation and planning after settling on what actions will be taken)

   5. Completely ready (all preparations and planning is complete, moving into action or have a worksite health program in place)

2a. If your answer to question 2 is e -- How long has your worksite health program been in place?

1. Not yet in place, all preparations and planning is complete, moving into action

2. Less than 1 year

3. 1-2 years

4. 3-5 years

5. More than 5 years

Please indicate your commitment to the requirements of the Work@Health^TM program by responding to the following questions.

3. Are you committed to allow your employees to participate in employer-sponsored worksite health programming during work hours?

___ Yes ___ No ___ Not sure

4. Are you willing to fully participate in Work@Health^TM data collection activities?

___ Yes ___ No ___ Not sure

5. Are you committed to fully participate in the Work@Health^TM training and technical assistance?

___ Yes ___ No ___ Not sure

6. Please respond to the following statement: “To the best of our ability we affirm that this company/organization will remain solvent and stable throughout the life of the Work@Health^TM Project.”

___ Yes ___ No ___ Not sure

7. Does your participation in Work@Health^TM depend upon the training being delivered on-line?

___ Yes ___ No

8. Why do you think your organization is a good candidate for the Work@Health^TM program?___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

9. What are your main reasons for wanting to participate in the Work@Health^TM Program?___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

10. What have been the particular hurdles that have kept you from implementing a comprehensive worksite health program in the past?_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

11. How did you hear about the Work@Health^TM Program?

    1. Through a business association (e.g., Small Business Association)

    2. Website

    3. Letter in the mail

    4. Newspaper

    5. Radio

    6. Colleague

    7. Word of mouth

    8. Other (please describe)________________________________________________________________________________________________________________________________________