1.Are you open to healthy changes in the workplace?

Yes

No

If yes, would you participate in a wellness program if offered to you at work? (Ex: Health promotion activity to support and encourage healthy choices and improve health outcomes at work and home). (Select if yes. If no, leave blank).

2.If you are interested in participating in wellness activities, what time of day are you willing to participate?

Before Work

After Work

At Lunchtime

At home activities with accountability challenges

3.What is your favorite form of physical activity?

Walking

Running

Group exercise (ex: Zumba, bootcamp, aerobics, etc.)

Strength Training

Treadmill

Yoga based activity

Other (please specify)

4.Please provide information relative to your stress level:

High- I often feel stressed and sometimes do not feel in control

Moderate- I sometimes feel stressed but often feel in control

Low- I rarely feel stressed and almost always feel in control

5.Which of the following incentives would best motivate you to make healthier lifestyle choices and participate in our worksite wellness program?

Prizes/Giveaways

Money/Gift Cards

Gym Membership Discount

Employee/Department Recognition

I don't need an incentive to participate

6.Please indicate which resources and educational programs you would like to see offered in our worksite wellness program:

Learning through webinars/seminars

Healthy cooking demos

Stress management and mental health

Smoking and tobacco cessation support

Physical activity

Wellness challenges

Weight loss support

Nutrition information and education

Diabetes

Heart health/Stroke

Cancer prevention

Ergonomics/Back pain

Walking programs

Self-empowerment topics

Clutter clearing

Zumba

Work/Life Balance/Goals/Planning

Yoga

Financial education

Other (please specify)