Appendix
About Your Employment and Workplace Wellness Program
If you are unsure about your workplace wellness program, we encourage you to speak to your supervisor and/ or manager to learn more about it before finishing this survey.
1. Please help selected the following answers for the questions below:
Questions/Answers Yes No Unsur
e Does your employer offer a workplace wellness
program?
Does your employer offer a specifically tailored wellness program for employees with disabilities?
Are you currently participating in an wellness program?
1a. If your employer does offer a specifically tailored wellness program or accommodations for employees with disabilities, please describe: *open ended”
2. What is the size of your employer?
a. Less than 15 employees b. 15 and 50 employees
c. Between 51 and 249 employees
d. Greater than or equal to 250 employees 3. Do you work:
a. Full-Time b. Part-Time
c. Others (please specify)
4. The type of industry or business in which your current job is located. (Select one option)
Accommodation and Food Services Wholesale Trade
Retail Trade (e.g., Food services and different types of stores)
Transportation and Warehousing Information and Technology Finance and Insurance
Real Estate and Rental and Leasing Educational Services
Professional, Scientific, and Technical Services Management of Companies and Enterprises Health Care and Social Assistance
Arts, Entertainment, and Recreation
Administrative and Support and Waste Management and Remediation Services
Other Services
5. Do you use the following wellness program at your workplace?
Selection/ Choices Yes No Not Available
The chronic illness self-management program Physical activity wellness program
Weight management wellness program Nutrition wellness program
Tobacco cessation wellness program Stress management wellness program Pain management program
Preventive screening wellness program Health education and literacy program Worksite flu shot clinic
Mental health and emotional wellness program
Financial wellness program Wellness portal and apps
Wellness coaching program
6. A. Does your employer offer any incentives for participating in the wellness/
fitness program? Yes/ No
B. Please select the type(s) of incentives offered for the employee
wellness/fitness programs offered by your employer: (will be a checkbox option) (source of selection; http://info.totalwellnesshealth.com/blog/4-questions-your-employees-have- about-wellness-programs)
● Free flu shots
● Yearly preventative health screenings
● Health education and resources
● Employer HSA/FSA contributions
● Onsite fitness or wellness classes
● Motivation, inspiration, and assistance for leading a healthier lifestyle
● Extra PTO
● Healthcare discounts or lower premiums
● Fun fitness and wellness challenges
● Gym memberships
● Gift cards or cash rewards
● Fun team outings and activities
C. Please select the type(s) of incentives offered for the employee
wellness/fitness programs that you were able to take part in: (will be a checkbox option)
● Free flu shots
● Yearly preventative health screenings
● Health education and resources
● Employer HSA/FSA contributions
● Onsite fitness or wellness classes
● Motivation, inspiration, and assistance for leading a healthier lifestyle
● Extra PTO
● Healthcare discounts or lower premiums
● Fun fitness and wellness challenges
● Gym memberships
● Gift cards or cash rewards Fun team outings and activities
7. How motivated are you to participate in the following employee wellness/fitness programs, if they are/were offered by your employer? On the scale of 1 to 5: 1 is not interested, 3 is neutral, and 5 being very interested
Selection/ Choices 1 2 3 4 5
The chronic illness self-management program Physical activity wellness program
Weight management wellness program Nutrition wellness program
Tobacco cessation wellness program Stress management wellness program Pain management program
Preventive screening wellness program Health education and literacy program Worksite flu shot clinic
Mental health and emotional wellness program Financial wellness program
Wellness portal and apps Wellness coaching program
Lifestyle and Health Habits:
8. How many alcoholic beverages (ex. beer, wine, and a mixed drink) do you consume per week?
_______ per week.
9. How many cans of soda do you drink per day? _______ can(s)
10.How many packs of cigarette do you smoke per week? (Select one option)
I do not smoke 0
1 2 3 4
5 or more
11.Do you have any of the following secondary health condition(s)?
SHC/ Problem Level Not a problem
Mild/
infrequent, problem
Moderate problem
Significant problem Bowel or bladder problems
Fatigue
Injury (e.g., falls)
Mental Health & depression Overweight and obesity Type 2 Diabetes
Pain
Pressure sores or ulcers Heart Disease(s)
12.Exercise. Yes/No
Do you exercise in a commercial gym?
Does your employer have an exercise and fitness facility?
If your company does have a fitness facility, do you exercise in your company’s exercise and fitness facility?
Do you exercise at your place of residence?
We would like to obtain information about your average activity level during your leisure time over the past month. In leisure time, we also include walking to work, to the shops and so on. (Question 15 to 29)
13.How many hours of sleep do you have in a day?
14.How many hours do you spend in sedentary leisure time (i.e., watching television, playing video games, and etc.)
15.Please select one for each activity type:
Light physical activities: Activities which do not increase your breathing rates, such as slow walking, or cycling, light swimming-pool exercise, swimming or gardening.
Moderate physical activity: Activity or exercise that increases your breathing rate or body temperature (perspiration), even if you can still keep talking while exercising. This includes brisk walking or cycling, walking on paths in nature, light jogging, moderately intensive gardening, pool exercise, aerobic and so on.
Vigorous physical activity: Activity or exercise that noticeably increases your breathing rate and perspiration, such as fast walking, jogging, other strenuous aerobic or weight training, ball games, gardening and so on.
Types of Activities/
Durations
< 0.5 hours/
week 0.5 - 1.5
hours/ week 2 - 4 hours/
week >4 hours/
week Light Physical
Activity Moderate
Physical Activity Vigorous
Physical Activity
Demographics:
16.In which U.S. state do you currently work?
17. Gender. (Select one option) a. Male
b. Female
c. Other (please specify)
18.Ethnicity or Race. (Select as many options as applicable) a. African American
b. American Indian/Alaska Native c. Asian American
d. Caucasian American e. Hispanic Americans f. Other (please specify)
19. Marital status. * (Select one option) a. Single
b. Married c. Divorced d. Separated
e. Living Together or Cohabiting f. Widowed
20. How old are you?
21. How much do you weigh in pounds?
22. How tall are you in feet and inches (e.g., 5 ft 11 in)?
23.Do you have the following disabilities?
a. Hearing difficulty. Are you deaf or have serious difficulty hearing?
b. Vision difficulty. Are you blind or have serious difficulty seeing even when wearing glasses?
c. Cognitive difficulty. Do you have serious difficulty concentrating, remembering, or
making decisions due to a physical, mental, or emotional condition?
d. Ambulatory difficulty. Do you have serious difficulty walking or climbing stairs?
e. Self-care difficulty. Do you have difficulty dressing or bathing?
f. Independent living difficulty. Do you have difficulty doing errands alone (e.g., visiting a doctor’s office or shopping) because of a physical, mental, or emotional condition?
24.What type(s) health insurance do you currently have? (Select * all that apply) a. Employer-based health insurance
b. Medicare or Medicaid c. Private Insurance d. Other (please specify) e. No healthcare coverage
25.What barriers or issues have you encountered while participating in a wellness program?
26.(Optional) If you would like to further discuss your experiences with workplace wellness programs as a person with a disability, please give us your contact information.
