2008-2009 Worksite Health Promotion Interest Survey

Elko County School District is in the process of developing an employee health promotion program and would like to learn about your interests in health promotion and health related activities. Please take a few minutes to complete this anonymous survey. Remember:

  • There is no right or wrong answer.
  • Feel free to skip any question you feel uncomfortable answering.
  • Your completion of this survey is completely voluntary.
  • The survey is administered by a third party to keep all responses anonymous. We will only receive a summary response for the entire group.
The survey needs to be completed by February 1, 2009. Thank you! If you are interested in helping the wellness committee please contact: Carol Banghart (753-8646) cbanghar@elko.k12.nv.us


  1. First tell us about yourself Gender:
    Male
    Female


  1. Age Group:
    Under 21
    23-30
    31-40
    41-50
    51-60
    60+


  1. Your Current Health Habits The following questions are about your current health habits and interest in pursuing a healthier lifestyle.) I exercise vigorously for at least 20 minutes three or more days per week.
    Yes
    No


  1. I would if:


  1. I regularly smoke cigarettes
    Yes
    No


  1. I would stop if:


  1. I am more than 20 pounds over my ideal weight.
    Yes
    No


  1. I would lose weight if:


  1. I avoid eating too much fat.
    Yes
    No


  1. I would if:


  1. I eat at least 5 servings of fruits and/or vegetables every day.
    Yes
    No


  1. I would if:


  1. I practice some type of stress management (i.e. exercise, meditation, prayer etc.) on a regular basis.
    Yes
    No


  1. I would if:


  1. I have had my blood pressure checked within the last year.
    Yes
    No


  1. I would if:


  1. How long has it been since your last regular checkup or physical?
    One year or less
    More than one year ago, but less than 18 months
    Two years or more


  1. I wear a seat belt all the time when I am in a motor vehicle.
    Yes
    No


  1. I would if:


  1. I have had a bout of low back pain in the last six months.
    Yes
    No


  1. I would do more to prevent it if:


  1. I have at least three drinks containing alcohol every day.
    Yes
    No


  1. I would drink less if:


  1. I usually consult medical self-care information online or from a book when I am sick or injured.
    Yes
    No


  1. I would if:


  1. I floss my teeth every day.
    Yes
    No


  1. I would if:


  1. I eat breakfast every day.
    Yes
    No


  1. I would if:


  1. Would you personally participate in a health promotion program if we offered one?
    Yes
    No


  1. Would you participate in any of the following wellness activities on a regular basis if they were offered at work? (Check all that apply)
    Exercise class
    Weight management program
    Confidential health screening
    Sports league activity
    Fitness or wellness contest(s)
    Walking club or event
    Monthly seminars
    Smoking cessation
    Personal health assessment
    Nutritional pot-luck


  1. Would you like a financial incentive to help motivate you to take better care of your own wellness?
    Yes
    No


  1. If yes, what kind of incentives would motivate you?


  1. Which of the following categories would you place yourself?
    I am not interested in pursuing a healthy lifestyle
    I have been thinking about changing some of my health behaviors
    I am planning on making a health behavior change within the next 30 days
    I have made some health behavior changes but I still have trouble following through with them
    I have had a healthy lifestyle for years


  1. In the last 6 months, how many days have you been absent from work due to illnesses or injuries?
    Never absent
    Less than 3 days
    More than 3 days, but less than 10
    More than 10 days


  1. Would you be interested in completing a confidential health survey that would give you a set of personal health recommendations?
    Yes
    No


  1. Please comment, including any suggestions on how we can structure our health improvement programs.