A strong foundation for employee health improvement

1. To what extent does the senior management in your business actively and visibly support the Worksite Wellness Program?

__ No support for the Worksite Wellness Program
__ Support, but not at senior level
__ Support at senior level, but not visible to workers
__ Strong and visible Worksite Wellness Program support
Comments:

2. Is the Worksite Wellness Program tied to your business’s mission statement?

__ No
__ Yes, the Worksite Wellness Program is tied to business plan OR mission statement
__ Yes, the Worksite Wellness Program is tied to both business plan and mission statement
Comments:

3. Is there an worker within your business whose job responsibilities include Worksite Wellness Program coordination?

__ No
__ Yes, but has little time available to dedicate to Worksite Wellness Program
__ Yes, and has at least part of the job dedicated to Worksite Wellness Program
__ Yes, and has at least one full-time position dedicated to Worksite Wellness Program
__ Yes, and has at least part of the job dedicated to wellness AND has a background that includes Worksite Wellness Program qualifications
__ Yes, our business has at least one full-time position dedicated to health improvement AND the worker’s background includes Worksite Wellness Program qualifications
Comments:

4. Does your business have an active wellness committee with diverse representation?

__ No (does not have a Worksite Wellness Program Committee, or has a committee that doesn’t meet)
__ Yes, we have a Worksite Wellness Program Committee, but with limited representation
__ Yes, we have a Worksite Wellness Program Committee with widespread representation
__ Yes, we have a Worksite Wellness Program Committee with widespread representation AND committee involvement is a component of each representative’s job responsibilities
Comments:

5. Does your business have an annual budget for Worksite Wellness Program expenses? (Worksite Wellness Program expenses may be associated with providing a health assessment, paying for behavior change programs/coaching programs, covering incentives and rewards that encourage healthy behaviors, subsidizing healthy food options, communications and activities around specific health topics, fitness centers/walking paths, etc).

__ No
__ Yes, but funds are earmarked for Worksite Wellness Programs (e.g. only for Weight Watchers or fitness discounts) and do not meet all existing Worksite Wellness Program needs
__ Yes, funds are available to meet current Worksite Wellness Program needs
Comments:

6. Does your business have a plan for engaging workers in the Worksite Wellness Program?

__ No
__ Yes, we have a communications plan for our Worksite Wellness Program
__ Yes, we have a communication plan AND we offer meaningful incentives or rewards (such as premium discounts or debit cards) for the Worksite Wellness Program to engage in healthy behaviors.
Comments:

A data-based approach to the Worksite Wellness Program

7. Does your business have clearly stated Worksite Wellness Program goals and priorities for employee health improvement?

__ No
__ Yes
__ Yes, data (e.g. HRA, claims, productivity) are the basis for defining Worksite Wellness Program goals or priorities
__ Yes, data AND evidence-based best practices are a basis for defining Worksite Wellness Program goals or priorities
__ Yes, data and best practices are basis for defining Worksite Wellness Program goals or priorities as well as measuring Worksite Wellness Program progress (evaluation)
Comments:

8. Has your business completed a Health Risk Assessment?

__ No
__ Yes, but more than 2 years ago
__ Yes, within the last two years, and achieved a participation rate of less than 50%
__ Yes, within the last two years, and achieved a 50% – 79% participation rate
__ Yes, within the last two years, and achieved an 80% or greater participation rate
Comments:

A worksite environment that supports healthy behaviors

9. Does your business’s tobacco reduction strategy reflect best practices?

(Check all that apply)
__ A no-smoking policy that includes both buildings AND grounds
__ 100% coverage for the cost of over-the-counter nicotine replacement therapy
__ Staff Member access to – and strong promotion of — a tailored stop-smoking program
Comments:

10. Does your business provide opportunities (time and places) for physical activity during the work day?

__ No
__ Yes, indoor places for physical activity (on-site fitness center) OR outdoor places for physical activity (walking paths)
__ Yes, both indoor AND outdoor places for physical activity
__ Yes, indoor and outdoor opportunities AND staff members can use work time for physical activity
Comments:

11. Does your business promote healthy eating by providing access to fruits and vegetables?

__ No
__ Yes, fruits and vegetables are available at the worksite (in vending machines, break areas, or cafeterias)
__ Yes, fruits and vegetables are available and discounted at the worksite
Comments:

Benefits that support employee health improvement

12. Does your business provide workers with self-care resources?

(Check all that apply)
__ Distribution of self-care books
__ internet-based access to health information
__ Nurse advice line
Comments:

13. Which of the following preventive services are covered at 100% by your business’s health benefits?

(Check all that apply)
__ Vision screening
__ Hearing
__ Immunizations (per CDC/ACIP recommendations)
__ Radiology
__ Laboratory services
__ STD screening
__ Preventive medical examination for adults
__ Cancer screen (includes: colon, cervical, breast, prostate and ovarian cancers)
__ Contraceptive management
Comments:

14. Which of the following are included in your business’s pharmacy benefit?

(Check all that apply)
__ Mail order or other 90-day supply option for medications
__ Specialty pharmacy network
__ Incentive-based tiered formulary design
Comments:

15. Do your business’s health benefits provide coverage for behavioral health (such as depression, mental illness, counseling, stress management, and chemical dependency)?

__ Yes, at the same level as medical benefits
__ Yes, but at a reduced level (less coverage) than medical benefits
__ No coverage for mental or behavioral health
Comments: