Create an Account Step 1 of 4 25% Your OrganizationWhat is the name of your organization?What is your organization's address? Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code What is your name? First Last What is your title?What is your work phone number?What is your work e-mail?* Which of the following best describes the industry for your organization?Agriculture, Forestry, FishingMiningReal Estate, Rental, and LeasingProfessional ServicesUtilitiesManagement of CompaniesAdministrative and Support ServicesEducational ServicesWholesale TradeRetail TradeConstructionManufacturingTransportation and WarehousingAccommodation and Food ServicesFinance and InsuranceArts, Entertainment, and RecreationPublic AdministrationHealth Care and Social AssistanceInformationOther Services, e.g., repair, personal, laundry or cleaning servicesType of businessFor profitNon-profitGovernmentDoes your organization currently provide health insurance to your employees?YesNo Number of EmployeesNumber of full-time, permanent employeesNumber of part-time, permanent employeesNumber of contracted/temp to perm/temp employeesTotal number of employeesThis is the # of full-time, permanent + # of part-time, permanent + # contracted/temp to perm/temp employees. What percentage of your employees earn $13.50 or less per hour (150% of the Massachusetts minimum wage)?Please enter a number from 0 to 100.Workforce CharacteristicsDescribe the racial/ethnic diversity within your workforce. (Enter a PERCENTAGE for each category)% Hispanic or LatinoA person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.% White (Not Hispanic or Latino)A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.% Black or African American (Not Hispanic or Latino)A person having origins in any of the black racial groups of Africa.% Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.% Asian (Not Hispanic or Latino)A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.% American Indian or Alaska Native (Not Hispanic or Latino)A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment.% Two or More Races (Not Hispanic or Latino)All persons who identify with more than one of the above five races.% Don’t knowTotal %Your workforce characteristics does not equal 100%Total of workforce characteristics is more than 100%Please enter a number from 99 to 100. Existing Worksite Health Promotion ProgramPlease select the description that best reflects your organization’s worksite health promotion program during the past year. A documented strategic plan for the programNonePartial or limitedAlready in placeAnnual budget for wellness expendituresNonePartial or limitedAlready in placeDesignated wellness championNonePartial or limitedAlready in placeWellness communication and marketing planNonePartial or limitedAlready in placeOpportunity for employees to learn personal health risk status (e.g., through screenings, health risk appraisal surveys)NonePartial or limitedAlready in placeOpportunity for employees to give input on program focus (e.g., through a needs and interest surveys, wellness committee or focus groups)NonePartial or limitedAlready in placeHealth education and awareness (e.g., health messages, classes, online learning, etc.)NonePartial or limitedAlready in placeBehavior change activities (e.g., coaching, skills practice, etc.)NonePartial or limitedAlready in placeSupportive environment and policies (e.g., healthy catering or vending policy, spaces for movement or exercise, etc.)NonePartial or limitedAlready in placeFinancial incentives for participation in wellness programs (e.g., subsidized gym memberships, health insurance premium discounts, gift cards, raffles)NonePartial or limitedAlready in place Organizational ReadinessPlease read each statement separately and select one response. Senior leadership is willing to dedicate financial resources to Working on Wellness.Strongly AgreeAgreeDisagreeStrongly DisagreeDon't KnowSenior leadership is willing to dedicate staff time to Working on Wellness.Strongly AgreeAgreeDisagreeStrongly DisagreeDon't KnowSenior leadership is proactive about making changes when problems are identified.Strongly AgreeAgreeDisagreeStrongly DisagreeDon't KnowThe organizational culture often encourages all employees to get involved in making decisions about health and safety topics.Strongly AgreeAgreeDisagreeStrongly DisagreeDon't KnowEmployees are willing to participate in Worksite Health Promotions activities.Strongly AgreeAgreeDisagreeStrongly DisagreeDon't KnowMost employees at my company could take time to participate in a group-based program.Strongly AgreeAgreeDisagreeStrongly DisagreeDon't KnowWithin my organization, management communicates frequently about all resources, programs and policies affecting the workforce.Strongly AgreeAgreeDisagreeStrongly DisagreeDon't KnowHow did you first hear about Working on Wellness?NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.