CDC Worksite Health Scorecard

Form Approved OMB No. 0920-XXXX Exp. Date: XX-XX-XXXX

CDC Worksite Health Scorecard

Public reporting of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, 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 currently 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).

Informed Consent

Before you get started, 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. Many parts of the project are being managed by ASHLIN Management Group (ASHLIN). ASHLIN is a private sector consulting firm with a focus in the area of health and human services 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 survey.

•     You were asked to participate because your workplace is participating in the Work@Health^TM program.

• Your participation in this survey is voluntary.  In the course of this survey, you may refuse to answer specific questions.  You may also choose to end the discussion at any time.

•     The survey is designed to take about 30 minutes. 

•    There are no right or wrong answers or ideas—we want to hear about YOUR experiences and opinions.

•    All of the comments 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 the aggregate as feedback from the group.  In our project reports, your name will not be linked to the comments you provide in this survey.

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

•    There are no personal risks or personal benefits to you for participating in this survey.

•     If you have any questions, you can contact Kristin Minot at Public Health Management Corporation.  Her phone number is 215-985-2519 and her email is Kristin@phmc.org.

Instructions

• Answer “yes” or “no” for each question on the tool.

• All questions should be answered consistently with your worksite practices and programs that are current or that have been in place within the last 12 months.

• There are 15 sections to the tool; you may complete each section in separate sittings and in any order. Individual scores can be tallied for each section and combined for an overall score once all sections are completed. The entire survey will take approximately 30 minutes to complete.

• We recommend that you form a small team, representing different organizational units to complete this survey together. A team-based approach will allow for more accurate responses, increase ownership and involvement amongst the team, and decrease effort for any single team member. Since a strong knowledge of your organization and its health promotion program(s) is recommended to accurately complete the tool, strive to pick team members who occupy the following positions:

o Members of a worksite health promotion committee

o Human resource managers

o Health benefits managers

o Health education staff

o Occupational nurses

o Medical directors

o Wellness directors

o Health promotion coordinators

o Building facilities managers

• Scan each section before attempting to respond. Answers to most questions are readily available following a review of organizational health policies (e.g., a policy handbook), benefit plan designs, interviews with key stakeholders, and direct observation. In some cases, answers may not be immediately obvious to the person assigned to complete the section. If you do not know the answer to the question, leave the box empty, and then engage others at the worksite to help you answer it.

• Some questions ask you to describe your health insurance plan. If your organization offers more than one health insurance option, refer to the health insurance plan with the highest enrollment.

• Throughout the survey, questions refer to “health promotion” at your worksite. This is also known as “worksite wellness” or “wellness programs”.

BACKGROUND INFORMATION

1. CONTACT INFORMATION

Name: __________________________________________________________________________

Job Title: ________________________________________________________________________

Address: _________________________________________________________________________

City___________________________________________

State or Territory__________________________

Zip Code_______________________________

Telephone number: ________________________________________________________________

E-mail address: ___________________________________________________________________

2. EMPLOYEE CHARACTERISTICS

2a. Number of employees (full and part time)

____ Total number of employees

2b. Sex

% Male ________

% Female ________

2c. Age group

% <18 years of age _________

% 18–34 years of age _________

% 35–44 years of age _________

% 45–64 years of age _________

% ≥65 years of age _________

2d. Average Age

Years of age __________

2e. Racial/ethnic group

% Non-Hispanic White __________

% Non-Hispanic Black/African American __________

% Hispanic/Latino __________

% Asian/Asian American __________

% American Indian/Alaska Native __________

% Native Hawaiian/Pacific Islander __________

% Other __________

2f. Work status

% Full-time _________

% Part-time _________

% Temporary _________

2g. Job type

% Salaried __________

% Hourly __________

2h. Education level

% Less than high school _________

% High school graduate/GED _________

% Some college/technical school _________

% College graduate _________

% Post-graduate/advanced degree _________

3. Your Organization’s Business Type (Choose One)

For-profit _________

Nonprofit/government _________

Nonprofit/other ________

4. Your Organization’s Industry Type:

Please select the category that best describes the primary purpose of your organization

____ Agriculture, Forestry, Fishing and Hunting

____ Mining, Quarrying, and Oil and Gas Extraction

____ Retail Trade

____ Wholesale Trade

____ Accommodation & Food Services

____ Professional, Scientific, & Technical Services

____ Transportation and Warehousing

____ Utilities

____ Health Care & Social Assistance

____ Real Estate & Rental & Leasing

____ Finance and Insurance

____ Information

____ Construction

____ Educational Services

____ Manufacturing

____ Management of Companies and Enterprises

____ Administrative & Support & Waste Management & Remediation Services

____ Arts, Entertainment, and Recreation

____ Public Administration

____ Other Services (except Public Administration)

5. Health insurance coverage provided to employees?

 Yes  No

5a. If yes, what is the percent of the employee population insured? ________%

5b. Does your organization “self-insure” its insurance plan(s)?

 Yes  No

6. Elements of worksite health promotion programs offered at your organization:

(check all that apply)

 Health education (e.g., skills development and behavior change classes; awareness building brochures, posters)

 Links to related employee services (e.g., referral to employee assistance programs (EAPs)

 Supportive physical and social environment for health improvement (e.g., tobacco free policies,

subsidized gym memberships)

 Integration of health promotion into your organization’s culture (e.g., health promotion being part of business’ mission statement)

 Employee screenings with adequate treatment and follow up (e.g., Health Risk Assessments (HRAs) and biometric screenings)

7. What incentives does your organization offer to encourage employee participation in health promotion activities?

___ None

___ Reduced insurance premiums/deductibles

___ Paid time off

___ Cash incentives (specify amount per person in USD) $_______

___ Competitions and prizes

___ Subsidized gym memberships

___ Merchandise (T-shirts, water bottles, etc.)

___ Other: ___________________

8. Over the next 12 months, what do you foresee for your organization’s financial investment in employee health promotion?

___ Will spend about the same

___ Will spend more

___ Will spend less

___ Don’t know

Organizational Supports
During the past 12 months, did your worksite:	Yes	No
1.   Conduct an employee needs and interests assessment for planning health promotion activities? Answer “yes” if, for example, your organization administers focus groups or employee satisfaction surveys to assess your employee health promotion program(s). Answer “no” if your organization administers general surveys that do not assess your employee health promotion program(s).
2.   Conduct employee health risk appraisals/assessments through vendors, onsite staff, or health plans and provide individual feedback plus health education? Answer “yes” if, for example, your organization provides individual feedback through written reports, letters, or one-on-one counseling.
3.   Demonstrate organizational commitment and support of worksite health promotion at all levels of management? Answer “yes” if, for example, all levels of management participate in activities, communications are sent to employees from senior leaders, the worksite supports performance objectives related to healthy workforce, and/or program ownership is shared with all staff levels.
4.   Use and combine incentives with other strategies to increase participation in health promotion programs? Answer “yes” if, for example, your organization offers incentives such as gift certificates, cash, paid time off, product or service discounts, reduced health insurance premiums, employee recognition, or prizes.
5.   Use competitions when combined with additional interventions to support employees making behavior changes? Answer “yes” if, for example, your organization offers walking or weight loss competitions.
6.   Promote and market health promotion programs to employees? Answer “yes” if, for example, your worksite’s health promotion program has a brand name or logo, uses multiple channels of communication, or sends frequent messages.
7.   Use examples of employees role modeling appropriate health behaviors or employee health-related "success stories" in the marketing materials?
8.   Tailor some health promotion programs and education materials to the language, literacy levels, culture, or readiness to change of various segments of the workforce? Answer “no” if you do not perceive a need for your organization to tailor its health promotion programs and education materials to any specific group(s).
9.   Have a health promotion committee?
10. Have a paid health promotion coordinator whose job (either part-time of full-time) is to implement a worksite health promotion program? Answer “yes” if implementing the employee health promotion program(s) at your worksite is included in a paid staff member’s job description or performance expectations.
11. Have a champion(s) who is a strong advocate for the health promotion program?
12. Have an annual budget or receive dedicated funding for health promotion programs?
13. Set annual organizational objectives for health promotion?
14. Include references to improving/maintaining employee health in the business objectives or organizational mission statement? Answer “no” if your organization’s business objectives or mission statement only reference occupational health and safety, without reference to improving the workforce’s health.
15. Conduct ongoing evaluations of health promotion programming that use multiple data sources? Answer “yes” if, for example, your organization collects data on employee health risks, medical claims, employee satisfaction or organizational climate surveys.
16. Make any health promotion programs available to family members?
17. Provide flexible work scheduling policies? Answer “yes” if, for example, policies allow for flextime schedules and work at home.
18. Engage in other health initiatives throughout the community and support employee participation and volunteer efforts? Answer “yes “if, for example, your organization supports participation in community events and school-based efforts, such as corporate walks, collaborate with state and local advocacy groups, health and regulatory organizations, and coalitions.

Tobacco Control
During the past 12 months, did your worksite:	Yes	No
1.  Have a written policy banning tobacco use at your worksite? Answer “yes” if your worksite adheres to a state-wide, county-wide, or city-wide policy banning tobacco use in the workplace.
2.   Actively enforce a written policy banning tobacco use? Answer “yes” if, for example, your worksite posts signs, does not have ashtrays, or communicates this written policy banning tobacco use through various channels at your worksite.
3.   Display signs (including ‘no smoking’ signs) with information about your tobacco-use policy?
4.   Refer tobacco users to a state or other tobacco cessation telephone quit line? Answer “yes” if, for example, your worksite refers tobacco users to 1-800-QUIT NOW or smokefree.gov
5. Provide health insurance coverage with no or low out-of-pocket costs for prescription tobacco cessation medications including nicotine replacement? Answer “yes” if, for example, your organization provides coverage for inhalers, nasal sprays, bupropion (e.g., Zyban) and varenicline (e.g., Chantix).
6.   Provide health insurance coverage with no or low out-of-pocket costs for FDA-approved over-the-counter nicotine replacement products? Answer “yes” if, for example, your organization provides coverage for nicotine replacement gum, patches, or lozenges.
7.   Provide or promote free or subsidized tobacco cessation counseling? Answer “yes” if these programs are provided on- or off-site; in group or individual settings; through vendors, on-site staff, health insurance plans/programs, community groups, or other practitioners.
8.   Inform employees about health insurance coverage or programs that include tobacco cessation medication and counseling?
9. Provide incentives for being a current non-user of tobacco and for current tobacco users that are currently involved in a cessation class or actively quitting? Answer “yes” if, for example, your organization provides discounts on health insurance or other benefits for non-smokers and tobacco users who are actively trying to quit.
10. Do not allow sale of tobacco products on company property? Answer “yes” if, for example, your worksite does not sell tobacco products on company property in vending machines or through on-site vendors. of tobacco products on company property (e.g., in vending machines or by vendors).

Nutrition
During the past 12 months, did your worksite:	Yes	No
1.   Provide places to purchase healthy food and beverages? Answer “yes” if, for example, your worksite provides vending machines, cafeterias, snack bars, or other purchase points. IF NO, PLEASE SKIP TO QUESTION 8.
2.   Have a written policy or formal communication that makes healthier food and beverage choices available in cafeterias or snack bars? Answer “yes” if, for example, the policy or formal communication makes vegetables, fruits, 100% fruit juices, whole grain items and trans-fat free/low-sodium snacks available in cafeterias or snack bars.
3.   Have a written policy or formal communication that makes healthier food and beverage choices available in vending machines? Answer “yes” if, for example, the policy or formal communication makes vegetables, fruits, 100% fruit juices, whole grain items and trans-fat free/low-sodium snacks available in vending machines.
4.   Make most (more than 50%) of the food and beverage choices available in vending machines, cafeterias, snack bars, or other purchase points be healthy food items? Answer “yes” if the healthy foods are items such as skim milk, 1% milk, water, unsweetened flavored water, 100% fruit juice, low-fat and low-sodium snacks, or fresh fruit.
5.   Provide nutritional information (beyond standard nutrition information on labels) on sodium, calories, trans-fats, or saturated fats for foods and beverages sold in worksite cafeterias, snack bars, or other purchase points?
6.   Identify healthier food and beverage choices with signs or symbols? Answer “yes” if, for example, your worksite puts a heart next to a healthy item near vending machines, cafeterias, snack bars, or other purchase points.
7.   Subsidize or provide discounts on healthier foods and beverages offered in vending machines, cafeterias, snack bars, or other purchase points?
8.   Have a written policy or formal communication which makes healthier food and beverage choices available during meetings when food is served? Answer “yes” if, for example, the policy or formal communication makes vegetables, fruits, 100% fruit juices, whole grain items or trans-fat free/low-sodium snacks available during meetings.
9.   Provide employees with food preparation and storage facilities? Answer “yes” if your worksite provides a microwave oven, sink, refrigerator, and/or kitchen.
10. Offer or promote an onsite or nearby farmers market where fresh fruits and vegetables are sold?
11. Provide brochures, videos, posters, pamphlets, newsletters, or other written or online information that address the benefits of healthy eating? Answer “yes” if these health promotion materials address the benefits of healthy eating as a single health topic or if the benefits of healthy eating are included with other health topics.
12. Provide educational seminars, workshops, or classes on nutrition? Answer “yes” if these sessions address nutrition as a single health topic or if nutrition is included with other health topics. These sessions can be provided in-person or online; onsite or offsite; in group or individual settings; through vendors, on-site staff, health insurance plans/programs, community groups, or other practitioners.
13. Provide free or subsidized lifestyle self-management programs that include advice or tools on healthy eating? Answer “yes” if these programs are provided in-person or online; onsite or offsite; in group or individual settings; through vendors, on-site staff, health insurance plans/programs, community groups, or other practitioners.

Physical Activity
During the past 12 months, did your worksite:	Yes	No
1.   Provide an exercise facility on-site?
2.   Subsidize or discount the cost of onsite and/or offsite exercise facilities?
3.   Provide environmental supports for recreation or exercise? Answer “yes” if, for example, your worksite provides trails or a track for walking/jogging, maps of suitable walking routes, bicycle racks, open space designated for recreation or exercise, a shower and changing facility.
4.   Post signs at elevators, stairwell entrances/exits and other key locations that encourage employees to use the stairs? Answer “no” if your worksite is located in a one-story building.
5.   Provide organized individual or group physical activity programs for employees (other than the use of an exercise facility)? Answer “yes” if, for example, your worksite provides walking or stretching programs, group exercise, or weight training.
6.   Provide brochures, videos, posters, pamphlets, newsletters, or other written or online information that address the benefits of physical activity? Answer “yes” if these health promotion materials address the benefits of physical activity as a single health topic or if the benefits of physical activity are included with other health topics.
7.   Provide educational seminars, workshops, or classes on physical activity? Answer “yes” if these sessions address physical activity as a single health topic or if physical activity is included with other health topics. These sessions can be provided in-person or online; onsite or offsite; in group or individual settings; through vendors, on-site staff, health insurance plans/programs, community groups, or other practitioners.
8.   Provide or subsidize physical fitness assessments, follow-up counseling, and exercise recommendations either onsite or through a community exercise facility?
9.   Provide free or subsidized lifestyle self-management programs that include advice on physical activity? Answer “yes” if these programs are provided in-person or online; onsite or offsite; in group or individual settings; through vendors, on-site staff, health insurance plans/programs, community groups, or other practitioners.

Weight Management
During the past 12 months, did your worksite:	Yes	No
1.  Provide free or subsidized body composition measurement, such as height and weight, Body Mass Index (BMI) scores, or other body fat assessments (beyond self-report) followed by directed feedback and/or clinical referral when appropriate?
2.   Provide brochures, videos, posters, pamphlets, newsletters, or other written or online information that address the risks of overweight or obesity? Answer “yes” if these health promotion materials address the risks of overweight or obesity as a single health topic or if the risks of overweight or obesity are included with other health topics.
3.   Provide educational seminars, workshops, or classes on weight management? Answer “yes” if these sessions address weight management as a single health topic or if weight management is included with other health topics. These sessions can be provided in-person or online; onsite or offsite; in group or individual settings; through vendors, on-site staff, health insurance plans/programs, community groups, or other practitioners.
4.   Provide free or subsidized one-on-one or group lifestyle counseling for employees who are overweight or obese? Answer “yes” if these programs are provided in-person or online; onsite or offsite; in group or individual settings; through vendors, on-site staff, health insurance plans/programs, community groups, or other practitioners.
5.   Provide free or subsidized lifestyle self-management programs that include advice or tools on weight management? Answer “yes” if these programs are provided in-person or online; onsite or offsite; in group or individual settings; through vendors, on-site staff, health insurance plans/programs, community groups, or other practitioners.

Stress Management
During the past 12 months, did your worksite:	Yes	No
1.   Provide dedicated space that is quiet where employees can engage in relaxation activities, such as deep breathing exercises?
2.   Sponsor or organize social events throughout the year? Answer “yes” if, for example, your worksite sponsors or organizes team building events, company picnics or employee sports teams.
3.   Provide stress management programs? Answer “yes” if these programs address stress management as a single health topic or if stress management is included with other health topics. Answer “yes” if these programs are provided in-person or online; onsite or offsite; in group or individual settings; through vendors, on-site staff, health insurance plans/programs, community groups, or other practitioners.
4.   Provide work-life balance/ life-skills programs? Answer “yes” if, for example, your worksite provides eldercare, childcare, referrals, tuition reimbursement, or other programs that are offered through vendors, onsite staff, or employee assistance programs.
5.   Provide training for managers on identifying and reducing workplace stress-related issues? Answer “yes” if, for example, your worksite provides training on performance reviews, communication, personnel management, assertiveness, time management, or conflict resolution.
6.   Provide opportunities for employee participation in organizational decisions regarding workplace issues that affect job stress? Answer “yes” if, for example, your worksite provides opportunities for employees to participate in decisions about work processes and environment, work schedules, participative problem-solving, and management of work demands.

Depression
During the past 12 months, did your worksite:	Yes	No
1.   Provide free or subsidized clinical screening for depression (beyond self-report) followed-by directed feedback and/or clinical referral when appropriate? Answer “yes” if these services are provided directly through your organization or indirectly through a health insurance plan.
2.   Provide access to online or paper self-assessment depression screening tools?
3.   Provide brochures, videos, posters, pamphlets, newsletters, or other written or online information that address depression? Answer “yes” if these health promotion materials address depression as a single health topic or if depression is included with other health topics.
4.   Provide educational seminars, workshops, or classes on preventing and treating depression? Answer “yes” if these sessions address depression as a single health topic or if depression is included with other health topics. These sessions can be provided in-person or online; onsite or offsite; in group or individual settings; through vendors, on-site staff, health insurance plans/programs, community groups, or other practitioners.
5.   Provide one-on-one or group lifestyle counseling for employees with depression? Answer “yes” if these programs are provided in-person or online; onsite or offsite; in group or individual settings; through vendors, on-site staff, health insurance plans/programs, community groups, or other practitioners.
6.   Provide training for managers on depression in the workplace? Answer “yes” if, for example, your worksite provides managers with training on how to recognize depression, productivity/safety issues, and company/community resources for managing depression.
7.   Provide health insurance coverage with no or low out-of-pocket costs for depression medications and mental health counseling?

High Blood Pressure
During the past 12 months, did your worksite:	Yes	No
1.   Provide free or subsidized blood pressure screening (beyond self-report) followed by directed feedback and/or clinical referral when appropriate?
2.   Provide brochures, videos, posters, pamphlets, newsletters, or other written or online information that address the risks of high blood pressure? Answer “yes” if these health promotion materials address the risks of high blood pressure as a single health topic or if the risks of high blood pressure are included with other health topics.
3.   Provide educational seminars, workshops, or classes on preventing and controlling high blood pressure? Answer “yes” if these sessions address preventing or controlling high blood pressure as a single health topic or if preventing and controlling high blood pressure are included with other health topics. These sessions can be provided in-person or online; onsite or offsite; in group or individual settings; through vendors, on-site staff, health insurance plans/programs, community groups, or other practitioners.
4.   Provide one-on-one or group lifestyle counseling and follow-up monitoring for employees with high blood pressure or pre-hypertension? Answer “yes” if these programs are provided in-person or online; onsite or offsite; in group or individual settings; through vendors, on-site staff, health insurance plans/programs, community groups, or other practitioners.
5.   Provide free or subsidized self-management programs for blood pressure control and prevention? Answer “yes” if these programs are provided in-person or online; onsite or offsite; in group or individual settings; through vendors, on-site staff, health insurance plans/programs, community groups, or other practitioners.
6.   Make blood pressure monitoring devices available with instructions for employees to conduct their own self assessments?
7.   Provide health insurance coverage with no or low out-of-pocket costs for blood pressure control medications?

High Cholesterol
During the past 12 months, did your worksite:	Yes	No
1.   Provide free or subsidized cholesterol screening (beyond self-report) followed by directed feedback and/or clinical referral when appropriate?
2.   Provide brochures, videos, posters, pamphlets, newsletters, or other written or online information that address the risks of high cholesterol? Answer “yes” if these health promotion materials address the risks of high cholesterol as a single health topic or if the risks of high cholesterol are included with other health topics.
3.   Provide educational seminars, workshops, or classes on preventing and controlling high cholesterol? Answer “yes” if these sessions address preventing and controlling high cholesterol as a single health topic or if preventing and controlling high cholesterol are included with other health topics. These sessions can be provided in-person or online; onsite or offsite; in group or individual settings; through vendors, on-site staff, health insurance plans/programs, community groups, or other practitioners.
4.   Provide one-on-one or group lifestyle counseling and follow-up monitoring for employees who have high cholesterol? Answer “yes” if these programs are provided in-person or online; onsite or offsite; in group or individual settings; through vendors, on-site staff, health insurance plans/programs, community groups, or other practitioners.
5.   Provide free or subsidized self-management programs for cholesterol/lipid control? Answer “yes” if these programs are provided in-person or online; onsite or offsite; in group or individual settings; through vendors, on-site staff, health insurance plans/programs, community groups, or other practitioners.
6.   Provide health insurance coverage no or low out-of-pocket costs for cholesterol/lipid control medications?

Diabetes
During the past 12 months, did your worksite:	Yes	No
1.   Provide free or subsidized pre-diabetes and diabetes risk factor assessment (beyond self-report) and feedback, followed by blood glucose screening and/or clinical referral when appropriate?
2.   Provide brochures, videos, posters, pamphlets, newsletters, or other written or online information that address the risks of diabetes? Answer “yes” if these health promotion materials address the risks of diabetes as a single health topic or if the risks of diabetes are included with other health topics.
3.   Provide educational seminars, workshops, or classes on preventing and controlling diabetes? Answer “yes” if these sessions address preventing and controlling diabetes as a single health topic or if preventing and controlling diabetes are included with other health topics. These sessions can be provided in-person or online; onsite or offsite; in group or individual settings; through vendors, on-site staff, health insurance plans/programs, community groups, or other practitioners.
4.   Provide one-on-one or group lifestyle counseling and follow-up monitoring for employees who have abnormal blood glucose levels (pre-diabetes or diabetes)? Answer “yes” if these programs are provided in-person or online; onsite or offsite; in group or individual settings; through vendors, on-site staff, health insurance plans/programs, community groups, or other practitioners.
5.   Provide free or subsidized self-management programs for diabetes control? Answer “yes” if these programs are provided in-person or online; onsite or offsite; in group or individual settings; through vendors, on-site staff, health insurance plans/programs, community groups, or other practitioners.
6.   Provide health insurance coverage with no or low out-of-pocket costs for diabetes medications and supplies for diabetes management (glucose test strips, needles, monitoring kits)?

Signs and Symptoms of Heart Attack and Stroke
During the past 12 months, did your worksite:	Yes	No
1.   Have posters or flyers in the common areas of your worksite (such as bulletin boards, kiosks, break rooms) that identify the signs and symptoms of a heart attack and also convey that heart attacks are to be treated as emergencies?
2.   Have posters or flyers in the common areas of your worksite (such as bulletin boards, kiosks, break rooms) that identify the signs and symptoms of a stroke and also convey that strokes are to be treated as emergencies?
3.   Provide any other information on the signs and symptoms of heart attack through emails, newsletters, management communications, websites, seminars or classes?
4.   Provide any other information on the signs and symptoms of stroke through emails, newsletters, management communications, websites, seminars or classes?

Emergency Response to Heart Attack and Stroke
During the past 12 months, did your worksite:	Yes	No
1.   Have an emergency response plan that addresses acute heart attack and stroke events?
2.   Have an emergency response team for medical emergencies?
3.   Offer access to a nationally-recognized training course on Cardiopulmonary Resuscitation (CPR) that includes training on Automated External Defibrillator (AED) usage?
4.   Have a policy that requires an adequate number of employees per floor, work unit, or shift, in accordance with pertinent state and federal laws, to be certified in CPR/AED?
5.   Have one or more functioning AEDs in place? IF NO, PLEASE PROCEED TO THE NEXT TOPIC.
6.   Have an adequate number of AED units such that a person can be reached within 3-5 minutes of collapse?
7.   Identify the location of AEDS with posters, signs, markers, or other forms of communication other than on the AED itself?
8.   Perform routine maintenance or testing on all AEDs?
9. Provide information to your local community Emergency Medical Service providers so they are aware that your worksite has an AED in place to faciliate emergency response?

Lactation Support
During the past 12 months, did your worksite:	Yes	No
1.   Have a written policy on breastfeeding for employees? Answer “yes” if the policy is included as a component of other employee policies or is a separate policy related to breastfeeding.
2.   Provide a private space (other than a restroom) that may be used by an employee to express breast milk?
3.   Provide access to a breast pump at the worksite?
4.   Provide flexible paid or unpaid break times to allow mothers to pump breast milk?
5.   Provide free or subsidized breastfeeding support groups or educational classes? Answer “yes” if these sessions address breastfeeding as a single health topic or if breastfeeding is included with other health topics. These sessions can be provided in-person or online; onsite or offsite; in group or individual settings; through vendors, on-site staff, health insurance plans/programs, community groups, or other practitioners.
6.   Offer paid maternity leave, separate from any accrued sick leave, annual leave, or vacation time?

Community Resources
During the past 12 months, did your worksite:	Yes	No
1.   Provide employees with health related information, programs, or resources from any of the following organizations (not including your own organization)? (Respond “yes” or “no” to all questions). Answer “yes” if health information, programs, or resources are provided in-person or online; on-site or off-site; or in group or individual settings.
1A. State/local public health agency
1B. Health insurance plan
1C. Health management program and/or wellness program provider / vendor
1D. Workers compensation provider
1E. Health Related Organizations (American Heart Association, American Cancer Society, etc).
1F. Health insurance broker
1G. Hospital
1H. YMCA
1I. Community Organization or Business Group (Wellness Council, Chamber of Commerce or other business group)
1J. Other (Respond “yes” if you work with an organization not listed above such as Employee Assistance Program, Food Services, etc. to provide health information, programs, or resources to employees.)
2.   Receive consultation (guidance, advise, training, and/or direction) from any of the following organizations related to the design and delivery of a worksite wellness program? (Respond “yes” or “no” to all questions)
2A. State/local public health agency
2B. Health insurance plan
2C. Health management program and/or wellness program provider / vendor
2D. Workers compensation provider
2E. Health Related Organizations (American Heart Association, American Cancer Society, etc).
2F. Health insurance broker
2G. Hospital
2H. YMCA
2I. Community or Business Organization (Wellness Council, Chamber of Commerce or other business group)
2J. Other (Respond “yes” if you receive consultation, advise or direction from an organization not listed above such as an Employee Assistance Program, Food Services, etc.)
3.   Participate in any Community Coalitions focused on health and / or business and community partnerships?

Occupational Health and Safety
During the past 12 months, did your worksite:	Yes	No
1.   Include improving or maintaining job health and safety in the business objectives or organizational mission statement? Answer “yes” if any written vision, planning, or guidance documents include language about improving or maintaining worker health and safety.
2. Have a written injury and/or illness prevention program? Answer “yes” if there is a written policy, whether or not it is posted.
3.   Employ or contract for an occupational health and safety professional? Answer “yes” if anyone is employed or contracted whose job includes improving health safety: example include occupational nurse, safety manager, environmental health manager, ergonomist, an insurance safety specialist who visits regularly.
4.   Encourage reporting of injuries and near misses? Answer “yes” if there is written and/or verbal encouragement to report injuries, illnesses, or near misses.
5.   Provided opportunities for employee input on hazards and solutions? Answer “yes” if, for example, there were all-hands meetings, tool box meetings, surveys, or focus groups for discovering and solving job health and/or safety issues.
6.   Have a program to investigate the cause of injuries or illnesses? Answer “yes” if, for example, all accidents are investigated to determine possible environmental causes such as conducting an analysis of root causes (RCA).
7.   Provide informational materials about health and safety at work to employees in most departments? Answer “yes” if, for example, there are health and safety newsletters, factsheets, posters, LED displays, emails, letters, broadcast messages, or other communications provided to employees.
8. Provide all new workers formal, comprehensive training on how to avoid accidents or injury on the job?
9.  Coordinate programs for occupational health and safety with programs for health promotion and wellness? Answer “yes” if, for example a new safety initiative also includes a wellness component such as attention to diet, physical activity, smoking, etc.).
10. Have the following policies or benefits for employees been in place:
10A. Paid time off (PTO) for days or hours due to illness of employees or dependents (full-time, non-exempt employees). [Note: non-exempt employees are those who are eligible to receive overtime pay if they work more than 40 hours in a week. Typically they are hourly workers.]
10B. Paid vacation time or personal days or hours to full-time, non-exempt employees.

Vaccine Preventable Diseases (VPD)
During the past 12 months, did your worksite:	Yes	No
1.   Provide health insurance coverage with no or low out-of-pocket costs for influenza (flu) vaccination?
2.   Provide health insurance coverage with no or low out-of-pocket costs for vaccinations other than influenza (flu) (e.g., pneumococcal or Tdap vaccines)?
3.   Conduct influenza (flu) vaccinations at your worksite? Answer “yes” if these offerings happen one or more times a year; are set up as either a temporary vaccine clinic run by an outside organization, internal occupational health staff or other arrangement. IF NO, PLEASE PROCEED TO QUESTION NUMBER 6.
4.   Provide influenza (flu) vaccinations at your worksite with no or low out-of-pocket costs to employees? Answer “yes” if these offerings happen one or more times a year; are set up as either a temporary vaccine clinic run by an outside organization, internal occupational health staff or other arrangement.
5.   Provide vaccinations other than seasonal influenza (e.g. pneumococcal or Tdap) at your worksite with no or low out-of-pocket costs to employees? Answer “yes” if these offerings happen one or more times a year; are set up as either a temporary vaccine clinic run by an outside organization, internal occupational health staff or other arrangement.
6.   Promote influenza (flu) vaccinations through brochures, videos, posters, pamphlets, newsletters or other written or online information that address the benefits of influenza vaccinations? Answer “yes” if these health promotion materials address the risks and benefits of influenza vaccination as a single health topic or if the benefits of influenza vaccinations are included with other health topics.

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