The following is a sample survey that you can modify to meet the needs of your workplace; for more information, see the OSH Answers on Workplace Health and Well-being Program - Getting Started. Surveys are frequently used in workplaces to gauge interest in the various aspects of a workplace health and well-being program.
Example of a Survey on Workplace Health and Well-being
Your responses will be used to help develop the program and to select which types of initiatives to offer. [ABC Company] is looking into the need for a workplace health and well-being program. We are interested in learning more about your ideas and interests.
Everyone is welcome to take a few minutes to complete this survey, which senior management has approved of.
We would like to keep this survey anonymous, so kindly do not include your name on it.
By [date/month/year], please complete and submit the survey.
a Male a Female
Non-Binary Would rather not comment
2. Age range:
under 21 21 - 30 31 - 40
41 - 50 51 - 60 over 60
3. If you have any health concerns regarding your family, yourself, or something related to your job, please quickly describe them.
4. Do you want [ABC Company] to assist you with these issues?
Definitely No Not sure
Explain your response, please.
5. Share your thoughts on the following assertions:
I generally enjoy my work.
I believe that the work I put in at work is fairly compensated.
My work-life balance makes me happy.
My level of control over my work is in line with the level of responsibility I am given.
6. If offered, would you take part in any of the following activities?
workouts involving aerobics
recreation group (e.g., baseball)
Please describe any additional workout regimens:
Guidelines for maintaining a healthy back
Advice for eating well (general tips, etc.)
Advice for managing your weight
Clinic for flu shots and other vaccinations
a blood pressure check
a blood glucose test
Advice on reducing stress
Education about substance use and abuse
Program to stop smoking
Workshop on interpersonal skills (such as """"Dealing with Difficult People"""", Conflict Resolution, etc.)
Workshop on retirement planning
Lunch and learn events
workshop for time management skills
Workshop on personal finances
How to balance work and life
Other: (please specify) (please specify)
7. What times of the day are you best able to engage in activities?
Time Period Day of the Week Season
Spring on Monday before work
Tuesday during Summer Lunch
Fall on Wednesday after work
Thursday evenings in the winter
Weekends (for family events) (for family events)
What additional elements influence involvement, if any?
8. In which location would you prefer to attend events?
In the office
at a posh fitness facility
in a local school, building, or hall
Other, please be more specific:
9. Would you be willing to contribute to the expense of a program, if necessary?
Anywhere from (please specify _______________) up to
10. Do you have any further questions or comments?"""