Workplace Health and Well-being - Sample Workplace Health and Well-being Survey

Workplaces often use a survey to determine interest in the various aspects of a workplace health and well-being program. The following is a sample. You can customize this survey according to the needs of your workplace. See the OSH Answers on Workplace Health and Well-being Program - Getting Started for more information.

Sample Workplace Health and Well-being Survey

[ABC Company] is looking into the need for a workplace health and well-being program. We are interested in learning more about your opinions and interests. Your answers will be used to help plan the program and to decide which types of initiatives to offer.

• Senior management has agreed to let everyone take a few minutes to complete this survey.
• Please do not put your name on the survey because we would like to keep this survey confidential.
• Please complete and submit the survey by [date/month/year]

1. Gender:

     Male      Female

     Non-Binary       Prefer not to say

2. Age Group:

     under 21      21 - 30      31 - 40     

     41 - 50      51 - 60      over 60

3. Do you have any health concerns about yourself, your family, or something arising from the workplace? If so, briefly describe your concerns.

4. Would you like [ABC Company] to help with these concerns?

     Yes       No      Not sure

Please explain your answer

5. Indicate how you feel about the following statements:

6. Would you participate in the following activities if offered?

7. When are you most able to participate in activities?

Day of the Week	Season	Time Period
Monday	Spring	Before work
Tuesday	Summer	Lunch time
Wednesday	Fall	After work
Thursday	Winter	Evenings
Friday
Weekends (for family events)

Are there other factors that affect participation? Please indicate

8. Where would you prefer to attend activities?

     In the workplace
     At a private health club
     At a local School or facility/hall
     Other, please specify:__________________

9. If necessary, would you be willing to share in the cost of a program?

     Yes    No

10. Do you have any additional comments or concerns?