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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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, Fishing Mining Real Estate, Rental, and Leasing Professional Services Utilities Management of Companies Administrative and Support Services Educational Services Wholesale Trade Retail Trade Construction Manufacturing Transportation and Warehousing Accommodation and Food Services Finance and Insurance Arts, Entertainment, and Recreation Public Administration Health Care and Social Assistance Information Other Services, e.g., repair, personal, laundry or cleaning services Type of business For profit Non-profit Government Does your organization currently provide health insurance to your employees? Yes No 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%HiddenTotal 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 program None Partial or limited Already in place Annual budget for wellness expenditures None Partial or limited Already in place Designated wellness champion None Partial or limited Already in place Wellness communication and marketing plan None Partial or limited Already in place Opportunity for employees to learn personal health risk status (e.g., through screenings, health risk appraisal surveys) None Partial or limited Already in place Opportunity for employees to give input on program focus (e.g., through a needs and interest surveys, wellness committee or focus groups) None Partial or limited Already in place Health education and awareness (e.g., health messages, classes, online learning, etc.) None Partial or limited Already in place Behavior change activities (e.g., coaching, skills practice, etc.) None Partial or limited Already in place Supportive environment and policies (e.g., healthy catering or vending policy, spaces for movement or exercise, etc.) None Partial or limited Already in place Financial incentives for participation in wellness programs (e.g., subsidized gym memberships, health insurance premium discounts, gift cards, raffles) None Partial or limited Already 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 Agree Agree Disagree Strongly Disagree Don’t Know Senior leadership is willing to dedicate staff time to Working on Wellness. Strongly Agree Agree Disagree Strongly Disagree Don’t Know Senior leadership is proactive about making changes when problems are identified. Strongly Agree Agree Disagree Strongly Disagree Don’t Know The organizational culture often encourages all employees to get involved in making decisions about health and safety topics. Strongly Agree Agree Disagree Strongly Disagree Don’t Know Employees are willing to participate in Worksite Health Promotions activities. Strongly Agree Agree Disagree Strongly Disagree Don’t Know Most employees at my company could take time to participate in a group-based program. Strongly Agree Agree Disagree Strongly Disagree Don’t Know Within my organization, management communicates frequently about all resources, programs and policies affecting the workforce. Strongly Agree Agree Disagree Strongly Disagree Don’t Know How did you first hear about Working on Wellness?CommentsThis field is for validation purposes and should be left unchanged.