Healthy Business Challenge Registration Form

This Challenge has been developed to assist workplaces to implement a health and wellness programme. It encourages workplaces to provide a supportive smoke-free environment and healthy policies for employees that promote physical activity, healthy eating, and mental wellbeing.
1.Contact Person *
2.Business/Organization Name *
3.Address: *
4.Work Phone #: *
5.Cell Phone #: *
6.Email Address: *
7.Number of Employees: *
8.Do you collect data related to employee health? *
9.How would you rate the overall health of your employees? *
Very Poor
Very Good
10.To what extent does senior management actively support employee health improvement? *
Not Supportive
Very Supportive
11.Do you have an existing Wellness Programme? *
12.Do you have a wellness plan? *
13.Do you have a Wellness Coordinator? *
14.Do you have a wellness committee? *
15.Does your company offer health insurance? *
16.How did you hear about the Healthy Business Challenge? Please select all that apply.