Free None - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 40098 (10/07)

STATE OF WISCONSIN Bureau of Community Health Promotion

WISCONSIN WORKSITE WELLNESS RESOURCE KIT SURVEY AND REQUEST
The Resource Kit is available for downloading at the following Department of Health and Family Services Web page: http://dhfs.wisconsin.gov/health/physicalactivity/index.htm or you may do a search on the Internet for WI Physical Activity. You may obtain a free hard copy by completing the `Ship To' information at the bottom of this form. So that we can better serve your needs, please complete the following information: 1. We are considering providing training for worksite wellness that would include information about: how to facilitate worksite wellness in your community and worksite; how to effectively use the Wisconsin Worksite Wellness Resource Kit; and how to evaluate worksite wellness efforts. If a regional train-the-trainer session were available for implementing worksite wellness programs, how likely is it that you would attend? Would not attend Unlikely to attend Somewhat likely Very likely Extremely likely

2. Which of the following best describes your company? Transportation Retail Construction Communication Health Care Finance Utilities Education Insurance Wholesale Agriculture Other: Manufacturing Government

3. What is your primary area of work? Human Resources Health Professional Benefits Administrator Other: 4. How would you describe your current worksite wellness program? We do not have a worksite wellness program, but we are considering it. We have begun planning for a wellness program and are looking for ideas. We have a wellness program, but we have a limited amount of programming. We have a well-established wellness program with a variety of programming activities as well as policy and environmental components. 5. How did you hear about the Resource Kit? Conference Internet Word of mouth Other: Occupational Health Policy Maker Union Representative Public Health Student Risk Manager Management Schools / Educator Wellness Committee

Ship to Information
Name Street / PO Box Telephone Agency City E-mail State Zip

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Mail this form to: WI Wellness Resource Kit · Wisconsin Division of Public Health · 1 West Wilson Street, Room 243 · Madison WI 53702. Or fax this to: 608-266-3125 or e-mail it to: [email protected].