WWKS - Food and Beverage Assessment

Food and Beverage Assessment

In developing a comprehensive worksite wellness initiative to address food and beverage, five strategies need to be employed: information, program, benefit design, policy, and environment.
Your worksite's individual responses to the survey will not be shared with anyone not affiliated with WorkWell KS. This survey will be used as an assessment to provide worksites with information about the steps your worksite can take to establish a worksite wellness initiative. Only aggregated results (with no worksite identifiers) may be published. If you have any questions regarding this survey, please contact Dr. Elizabeth Ablah at 316-293-2627 (eablah@kumc.edu).
Name of worksite*
Primary contact at worksite*
Contact email*
example@example.com
County*
Zip*
City*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Approximate number of employees
Not counting temporary or seasonal
Approximate number of employee dependents
Spouses and children
What industry type best describes your worksite?

Agriculture, Forestry, Fishing, and HuntingMining, Quarrying and Oil and Gas ExtractionUtilitiesConstructionManufacturingMachinery, Equipment, and Supplies Merchant WholesalersRetail TradeTransportation and WarehousingInformationFinance and InsuranceReal Estate, Rental, and LeasingProfessional, Scientific, and Technical ServicesEducational ServicesHealthcare and Social AssistanceArts, Entertainment, and RecreationAccommodation and Food ServicesGrant Making and Civic OrganizationsPublic Administration (including health departments)Other
Information

Does your worksite post nutrition information at meetings/events, potlucks/breakrooms, vending machines/mini markets, or cafeterias to assist in the identification of: *

Rows	Yes	No
Healthy foods
Healthy beverages

Does your worksite promote (e.g., signage, communications campaign) for:*

Rows	Yes	No
Healthy foods at the worksite
Healthy beverages at the worksite

Has your worksite conducted an educational campaign to INCREASE consumption in: *

Rows	Yes	No
Healthy foods
Healthy beverages

Has your worksite conducted an educational campaign to DESCREASE consumption in: *

Rows	Yes	No
Unhealthy foods
Unhealthy beverages

Does your worksite use promotional messages to address any of the following:*

Rows	Yes	No
Taste of healthy foods?
Nutrients/health benefits of healthy foods?
Taste of healthy beverages?
Nutrients/health benefits of healthy beverages?

1:Calc:Value Scale Total
1:Calc:Score
1:Calc Percent
Program
Does your worksite offer or host a farmer's market or community supported agriculture (CSA) where fresh fruits and vegetables are sold?*

YesNo
Does your worksite provide access to a '5 a Day' nutritional program or some other nationally recognized program promoting the regular consumption of fruits and vegetables?*

YesNo
Does your worksite offer a program that promotes employees to change their diets to be more healthful through any of the following: (select all that apply):

Positive messaging (e.g. promote tastefulness of healthy foods)Incentives (e.g., discount on salad bar, reduce pricing on fruits/vegetables)Goal development (e.g. encourage five servings of fruit and beverages a day)Socially supportive techniques (e.g. doing with coworker, engaging family/friends)Regular contact with a dietitian
2:Value Scale - total
2:Calc:Score
2:Calc Percent
Benefits
Does your worksite subsidize community supported agriculture (CSA) membership(s) for employees, departments, or the entire workplace?*

YesNo
Does your worksite's benefit plan include at least one benefit design strategy (e.g, health insurance premium reductions, paid time off) to encourage employees to eat/drink healthy foods/beverages?*

YesNo
Does your health insurance or worksite cover a nutritional consultation with a dietitian for any interested employee?*

YesNo
Does your worksite subsidize or provide coupons or vouchers for healthy foods/beverages that can be purchased on-site (e.g., cafeteria, mini-market, vending)?*

YesNo
3:Calc:Value Scale Total
3:Calc:Score
3:Calc Percent
Policy

Has your worksite adopted standards that define ‘healthy’:*

Rows	Yes	No
Foods
Beverages

Does your worksite have a written policy that governs the offering of foods at your facility?*

YesNo
Does your worksite’s policy prevent the sale of unhealthy foods (i.e., high calorie, high fat, high sugar, or high sodium foods)?*

YesNo

Does your worksite’s policy prevent the sale of low-nutrient beverages?*

YesNo
4:CalcValue Scale Total
4:Calc:Score
4:Calc Percent
Environment

At your worksite, please answer if each of the following statements are true. *

Rows	Yes	No
Fruits are available in sufficient quantities on a consistent basis
Fruits are sold at prices that are either affordable or free
Fruits are promoted to employees
Vegetables are available in sufficient quantities on a consistent basis
Vegetables are sold at prices that are either affordable or free
Vegetables are promoted to employees
Other healthy foods are available in sufficient quantities on a consistent basis
Other healthy foods are sold at prices that are either affordable or free
Other healthy foods are promoted to employees
Healthy beverages are available in sufficient quantities on a consistent basis
Healthy beverages are sold at prices that are either affordable or free
Healthy beverages are promoted to employees

Does your worksite provide any of the following: (select all that apply)

Safe, unflavored, cool drinking water to employees at no costDrinking fountain/water bottle dispenserFruit infused waterFiltered water

In your opinion please indicate what percentage of the food/beverage offerings are healthy at your worksite. *

Rows	0%	1-25%	26-50%	51-75%	76-100%
Foods
Beverages

5:Calc Value Scale - Total
5:Calc:Score
5:Calc Percent
Should be Empty:

Food and Beverage Assessment

Information

Program

Benefits

Policy

Environment