FFLAG Worksite Application
FFLAG Worksite Wellness is committed to helping organizations support healthy choices in physical activity, healthy eating and tobacco prevention through policies, programs and environmental changes. The FFLAG Worksite Wellness Award celebrates worksites that place a high value on employee health and overall well-being, while taking steps to help them plan for cost effective strategies to create a healthier workforce.

The FFLAG Worksite Wellness application will allow worksites to assess their current employee wellness practices and be rewarded for efforts already in place – such as health screenings offered through an insurer, tobacco-free policy,  and other initiatives that promote a healthy workforce. The worksite will receive a score based on their efforts, which will translate into a bronze, silver, gold or platinum award level. Recognized worksites will also have access to technical assistance to further improve the health of their work environment that can help them reach higher recognition levels in the future.

We are excited that your business is participating in the 2017 FFLAG Worksite Wellness Award program! Contact Elizabeth Steffer at elizabeth.steffer@nkyhealth.org or 859-363-2093 with questions.
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CONTACT INFORMATION/ DEMOGRAPHICS
Organization name *
Address *
Organization contact person *
Phone number *
E-mail address *
What type of organization do you represent (i.e. government agency, non-profit, school, manufacturing, healthcare, etc)? *
Number of total employees (full and part-time) *
Does your current health insurance offer wellness benefits to the employees (i.e. Go365)? *
Is your organization a member of the FFLAG Coalition? *
What is the common process of policy development and implementation? *
If you selected "other" for the question above, please describe in general your organization's policy development and implementation process:
SENIOR MANAGEMENT SUPPORT *
 Mark all that apply  *MUST include letter of support from senior management to be eligible to apply.
Yes
No
a. Does senior leadership support worksite wellness programs and policies?
b. Does your organization have a key employee (i.e. wellness coordinator) that allocates at least 5% of their time towards worksite wellness initiatives?
c. Does your organization have allocations designated for worksite wellness initiatives?
WELLNESS TEAM *
Mark all that apply
Yes
No
a. Has your organization identified a wellness leader/team?
b. Does your wellness team meet at least twice a year to plan and evaluate?
c. Is there a designated employee that attends worksite wellness trainings sponsored by FFLAG or other affiliated organizations?
How long has your wellness team been in place? *
ASSESSMENT *
Mark all that apply. **Please provide copies of any assessment tools you use, if applicable.
Yes
No
Does your organization conduct employee interest surveys to better understand employee health needs?
Does your organization conduct an annual health and wellness survey with the employees?
Does your organization provide annual onsite health screenings (i.e. blood pressure, cholesterol, blood sugar) to employees?
Does your organization compare annual health and wellness surveys and onsite health screenings to baseline data?
ACTION PLAN *
Mark all that apply. **Please provide copies of any worksite wellness action plans created, if applicable.
Yes
No
Does your organization have a worksite wellness action plan?
Does your action plan have a clear mission/vision statement developed for worksite wellness initiatives? (every year)
Does the action plan have specific goals and measurable objectives for worksite wellness initiatives?
PROGRAMMING: Has your organization implemented any of the following HEALTH AWARENESS programs? *
Health awareness programs increase the participant's awareness or interest in a health topic such as diabetes, heart disease, common health screenings for different age groups, stress management, etc.  Actual behavior change or improvement in health does not usually happen as a result of these types of programs; however, awareness is a key first step that helps lead an individual to change behavior.
Yes
No
Promotion of local community wellness events/programs to employees.
Health fair/health screenings for employees
Monthly/weekly wellness-related messaging to employees
Lunch and Learns on various wellness/health topics
Sponsoring local 5K run/walks
Active promotion of 1-800-Quit Now
If there are any other HEALTH AWARENESS programs your organization has implemented related to worksite wellness, please describe below.
PROGRAMMING: Has your organization implemented any of the following HEALTH BEHAVIOR programs? *
Behavior change programs aim for participants to build the skills necessary to successfully change a less healthy behavior.  These programs provide goals for participants, such as eating 5 fruits/vegetables a day, being physically active at least 3 days a week, etc.  During the program, participants are then provided resources (such as tracking charts, additional education) to help them reach their goals.
Yes
No
Diabetes education program
Nutrition education program
Weight management programs (i.e. Weight Watchers)
Physical activity programs/ challenges (i.e. tracking steps, boot camps, etc)
Health coaching offered to employees (i.e. through insurance provider)
Tobacco cessation program
Offer Employee Assistance Programs (EAP)
If there are other HEALTH BEHAVIOR programs your organization has implemented related to worksite wellness, please describe below.
SUPPORTIVE ENVIRONMENTS: Does your organization include any of the following? *
Yes
No
Designated lunch area equipped with a clean refrigerator and microwave
Vending area that serves healthy food options
Cafeteria that serves healthy food options
Healthy guidelines for catered/purchased foods for company meetings
No-cost fresh/filtered water
Designated "employee wellness" educational display area onsite
Allow for shared use of conference rooms/open space for worksite wellness-related activities (such as lunch and learns or fitness activities)
Point-of-Decision Making Prompts (signage) near elevators that promote stair use
Designated and marked areas for walking using existing structures (i.e. parking lot)
Designated and marked areas for walking through constructed walking path
Fitness facility onsite for employee use
Offer negotiated employee discounts with local fitness facilities
Bike racks/storage onsite
Appropriate breastfeeding area(s) for mothers
If there are any other SUPPORTIVE ENVIRONMENT efforts your organization has implemented related to worksite wellness, please describe below.
POLICY: Does your organization currently have any of the following policies related to worksite wellness? *
**Please provide copies of any wellness-related policies, if applicable.
Yes
No
100% Tobacco-free grounds (no tobacco use allowed on property or in company vehicles)
Written policy that prohibits indoor tobacco use
Written policy making healthier foods/beverages available in cafeteria, snack bars or vending machines
Written policy making healthier foods/beverages available during sponsored meetings where food is served
Flexible work schedules that would allow employees to add physical activity into their day (walking meetings, encouraging 5-10 minute walk breaks, etc)
Written policy on injury and/or illness
Written policy on following OSHA (Occupational Safety and Health Administration) regulations
Written policy on breastfeeding
Written policy on mental health and/or Employee Assistance Programs (EAP)
A comprehensive worksite wellness policy (encompasses several aspects of health in one policy document-- tobacco cessation, healthy eating, physical activity, breastfeeding and so on)
If there are any other POLICIES your organization has implemented related to worksite wellness, please describe below.
EVALUATION: How does your organization measure the effectiveness of your wellness initiatives? *
Mark all that apply. **Please provide copies of any evaluation tools you use, if applicable.
Yes
No
Employee participation/satisfaction survey
Improvement in employee awareness/knowledge of wellness topic(s)
Changes in employee health behaviors
Changes in employee health risks
Comparison of annual health and wellness surveys and onsite health screenings to baseline data
If there are any other EVALUATION MEASURES your organization has collected related to worksite wellness, please describe below.
BONUS: Has your organization applied for and received any other local or national awards/recognition for your worksite wellness efforts? Please select all that apply.
BONUS: Did you upload worksite wellness-related photos to the FFLAG Google Drive folder?
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