1. Name: __________________________________________

2. Gender: Male Female

3. Age: Under 21 21-30 31-40 41-50 51-60 Over 60 Prefer not to answer

4. I am satisfi ed with my current state of health.

Yes No

5. I would participate in health improvement activities at work if they were offered.

Yes No

6. Which health topics are you interested in learning more about? (Check all that apply.)

Exercise/fi tness Healthy eating Heart health Prevention

Stress management Tobacco cessation Weight management

Other: ________________________________________

7. How would you like to receive health information at work?

Email Staff meetings Newsletters

Posters/handouts Seminars Classes

Other: ________________________________________

8. When are you most likely to participate in these activities? (Check all that apply.)

Monday Tuesday Wednesday Thursday Friday

Morning/before lunch During lunch Afternoon/after lunch Evening/after work

9. In which of the following activities would you participate if offered at work? (Check all that apply.)

Walking group Healthy cooking class Weight-loss challenge Healthy recipe contest Outdoor scavenger hunt On-site tobacco cessation classes Commute by bicycle/foot challenge Healthy potluck Other: ________________________________________

10. If incentives or rewards were offered for participation, which would you prefer?

Merchandise(T-shirts, water bottles, etc.)

Cash Gift cards Extra paid time off

Other: _________________________________________________________

11. What types of activities related to health and healthy lifestyle would you welcome at your workplace, and in which would you participate?

Thank you for participating in this survey. Your input is greatly appreciated.

Employee Interest Survey

13-00855_A