Wellness Program Survey

Data collected from the following survey will help us in evaluating the feasibility of various elements that could be included in a program designed for our organization. Please answer the following questions:



A red asterisk (*) indicates required questions.


  1. Gender
    Male
    Female


  1. What is your age range?
    18-25
    26-32
    33-40
    41-50
    51+


  1. Sedgwick CMS currently has several wellness related programs in place. Please check all with which you are familiar.*
    Disease Management Program- Asthma, Coronary Artery Disease, Diabetes, Chronic Heart Disease
    Employee Assistance Program
    Flu shot benefit


  1. How important is the availability of the following components of a wellness program to you? Please rate the following as important or not important.*

            1 2      
      Disease Management Program- Asthma, Coronary Artery Disease, Diabetes, Chronic Heart Disease Important Not Important   
      Employee Assistance Program Important Not Important   
      Flu shot benefit Important Not Important   


  1. Below are additional components that may be included in a company’s Wellness program. Please rate your interest in the following. Please indicate your opinion ranging from “strongly interested” to “strongly disinterested” for the following:*

            1 2 3 4 5 6 7      
      Walking program Strongly Interested Strongly Disinterested  
      Health fairs Strongly Interested Strongly Disinterested  
      Health related team competitions Strongly Interested Strongly Disinterested  
      Smoking cessation program Strongly Interested Strongly Disinterested  
      Discount to a fitness facility Strongly Interested Strongly Disinterested  
      Discount to a vitamin store Strongly Interested Strongly Disinterested  
      Weight Watchers Strongly Interested Strongly Disinterested  
      Health newsletter Strongly Interested Strongly Disinterested  
      Lunch and learns Strongly Interested Strongly Disinterested  
      Blood drive Strongly Interested Strongly Disinterested  
      Mobile mammography Strongly Interested Strongly Disinterested  


  1. The next several questions will be about health issues many people experience. For each item, please indicate if you have or have not given thought to the issue. If you have attempted to make a change, please also indicate if you experienced long term success or if you were not successful.

    LOSE WEIGHT*
    Not an issue/Never thought about
    Thought about


  1. If you have attempted to lose weight, what level of success did you experience? If weight is not an issue for you or if you have never thought about it, please choose N/A.*
    Long term success
    Short term success
    Not successful
    N/A


  1. CHANGE THE KINDS OF FOODS EATEN*
    Not an issue/Never thought about
    Thought about


  1. If you have attempted to change the kinds of foods eaten, what level of success did you experience? If this is not an issue for you or if you have never thought about it, please choose N/A.*
    Long term success
    Short term success
    Not successful
    N/A


  1. BECOME MORE PHYSICALLY ACTIVE*
    Not an issue/Never thought about
    Thought about


  1. If you have attempted to become more phsycially active, what level of success did you experience? If this is not an issue for you or if you have never thought about it, please choose N/A.*
    Long term success
    Short term success
    Not successful
    N/A


  1. REDUCE STRESS*
    Not an issue/Never thought about
    Thought about


  1. If you have attempted to reduce stress, what level of success did you experience? If this is not an issue for you or if you have never thought about it, please choose N/A.*
    Long term success
    Short term success
    Not successful
    N/A


  1. STOP TOBACCO USE*
    Not an issue/Never thought about
    Thought about


  1. If you have attempted to stop tobacco use, what level of success did you experience? If this is not an issue for you or if you have never thought about it, please choose N/A.*
    Long term success
    Short term success
    Not successful
    N/A


  1. STOP ALCOHOL OR SUBSTANCE ABUSE*
    Not an issue/Never thought about
    Thought about


  1. If you have attempted to stop alcohol or substance abuse, what level of success did you experience? If this is not an issue for you or if you have never thought about it, please choose N/A.*
    Long term success
    Short term success
    Not successful
    N/A


  1. Have you ever participated in a company sponsored wellness program at a previous employer?*
    Yes
    No


  1. If you answered "Yes" to the previous question, please list the components of that program.


  1. Out of those components you listed in the previous question, please indicate which you liked best and which you liked least.


  1. Are you certified in CPR or First Aid?
    I am certified in CPR only.
    I am certified in First Aid only.
    I am certified in both CPR and First Aid.
    I am not certified in either.