EMPLOYEE WELLNESS SURVEY

Thank you for completing this survey. Your response will give us insight into the types of
activities that are of interest to you. Participation in this survey is voluntary, and you do not
need to respond to any of the questions that you do not wish to answer. The survey will
take about five minutes. The information you provide on this survey is confidential and will
only be viewed by our Worksite Wellness staff. A summary will then be presented to your
wellness representative.

1. Please indicate the programs - events you would participate in.	Aerobic - Cardio classes Weight management program Yoga - Pilates - Stretching Fitness Challenges Walking event or club Monthly wellness seminars Healthy cooking class Potluck for nutritional foods Stress Management Sculpt N Toning Other
2.Would you be more likely to participate in a wellness program if it was offered at you place of employment or off-site at an alternate location?
3.Do you prefer to participate in activities as part of a group or individually?
4.What would you hope to experience by participating in a wellness program?	Lose weight Increase energy Reduce joint pain Improve Back strength Improve sleep patterns Reduce stress Sculpt and tone problem areas Increase muscle strength Improve overall fitness Rehabilitate injury Other
5.What do you consider the most likely reasons for not participating in a fitness program?	Dislike physical activity Lack of motivation Lack of results Unsure of what to do Limited time Other
6.Would you be more inclined to participate in a program if it was offered?
7.How many days could you commit to improving your health and fitness each week?
8.How much time could you commit?
9.Any other interest or suggestions. Please list any comments, questions or concerns you may have about offering wellness - fitness services at your worksite. Your input is very important.
10.Are you interested in being part of a wellness committee or planning wellness programs and or activites?
* Employer
* Name
Phone
* E-mail address