Work Site Assessment YMCA association/CHLI number:

Assessment date:

Name of Community team: CHLI point person: Names of CHLI Coordinators assigned to work site:

Names and titles of individuals interviewed at work site:

I. General Information 1. Name of employer/work site: 2. Number of full- or part-time employees at physical location of work site:

employees

If a multisite employer, approximate total number of full- or part-time employees at all sites employees combined: 3. Type of employer/work site: ¨ Private ¨ Public/government

¨ Not-for-profit

4. Location of work site: 4.a. Zip code: 4.b. County:

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5. Work site setting (check the best description): ¨ Urban

¨ Suburban

¨ Rural

R  ough definitions of urban, suburban, and rural settings are below. Recognize that these are only general guidelines and each situation may be unique. • Urban: an area that has an assortment of shopping destinations, a school, a place of worship, park or recreational facilities, or other community destinations less than or equal to a half mile or a 10-minute walk from most homes • Suburban: an area that has an assortment of shopping destinations, a school, a place of worship, parks or recreation facilities, or other community destinations approximately one mile or a 20-minute walk from most homes • Rural: an area that has an assortment of shopping destinations, a school, a place of worship, parks or recreational facilities, or other community destinations greater than or equal to two miles or a 40-minute or longer walk from most homes 6. Ethnic makeup of the employees at the work site (provide an approximate percentage for each category to add up to 100 percent). Note that the federal government considers race and Hispanic origin to be two distinct concepts. This question asks only about Hispanic origin. The following question asks about the race.

% Spanish, Hispanic, or Latino (of any race)



% Not Spanish, Hispanic, or Latino (of any race)

7. Racial makeup of the employees at the work site (provide an approximate percentage for each category to add up to 100 percent).

% White



% Black or African-American



% American Indian and Alaska Native



% Asian



% Native Hawaiian and Other Pacific Islander



% Some other race/two or more races

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II. Programs, Physical Environment, Promotion, and Policy The CHLI assessment process is not a measure of success or failure but rather an important part of developing a plan for improvement in your community. Please be candid and accurate as you answer the questions below. Note: These questions apply to the work site currently undergoing assessment; if you are a multisite employer, consider only the physical site being assessed.

A. Administrative support/general 1. The work site has a wellness committee/wellness ¨ coordinator whose efforts focus on enhancing physical activity and healthy eating opportunities at the workplace.

2. The work site has a health-promotion budget that covers the cost of offering employees opportunities for physical activity and healthy eating.

3. The work site’s mission statement includes commitment to employee health and well-being. 4. The work site has organizational and performance objectives pertaining to employee health and well-being. 5. The work site offers employees a health insurance plan that covers preventive services, such as annual physical exams and age-appropriate health screenings (e.g., blood cholesterol testing, pap smear, mammography, colonoscopy). 6. The work site (or its health insurance plan) rewards employees for participating in preventive health and wellness activities (e.g., smoking cessation program, weight management program, physical activity program). 7. The work site contributes money, staff, products, or services to community-wide efforts to increase opportunities for physical activity in the community (e.g., donations for building physical-activity-friendly facilities, sponsoring sports teams, staff time for community coalition meetings, etc.). 8. The work site contributes money, staff, products, or services to community-wide efforts to increase opportunities for healthy eating in the community (e.g., donations for farmers markets and food banks, sponsoring community gardens, staff time for community coalition meetings, etc.).

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¨

Yes

¨

¨

Covers all/ Usually most costs covers costs 81%–100% 61%–80%

¨

¨

In development

¨

No

¨

Covers half the costs 41%–60%

Covers some costs 21%–40%

¨

Rarely/ never covers costs 0%–20%

Yes

¨

In development

¨

¨

No

Yes

¨

In development

¨

¨

No

Yes

¨

In development

¨

¨

No

Yes

¨

In development

¨

¨

No

Yes

¨

In development

¨

¨

¨

¨

Yes

In development

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A. Administrative support/general (continued) 9. The work site offers a smoke-free environment. ¨ Yes

Rate your confidence in your answers for this section:

¨

Very high

¨

High

¨

¨

In development

¨

Medium

No

¨

Low

¨

Very low

B. Health promotion 1. The work site conducts health promotion and wellness needs assessments/surveys to understand the wellness needs of the employees and to plan work site health promotion activities accordingly.

¨

¨

Yes

¨

In development

No

2. T  he work site offers one or more health promotion services (e.g., fitness assessments, health risk appraisals, healthy eating classes, weight management programs, individually adapted behavior-change programs, physical activity classes, smoking cessation programs): 2.a. To the employees

¨

¨

Yes, offered free 2.b. To the employees’ family members

¨

4. T  he work site offers preventive health services/ screenings on-site or access to services/ screenings off-site (e.g., blood sugar measurement, cholesterol measurement, flu shots): 4.a. To the employees

¨

Yes

¨

Always/almost always 81%–100%

¨

Usually 61%–80%

¨

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¨

¨

¨

About half 41%–60%

No

¨

Sometimes 21%–40%

¨

¨

≥ 4x / yr

No, not offered

No, not offered

¨

¨

Yes, offered fee-based

¨

3x / yr

¨

2x / yr

¨

Rarely/ never 0%–20%

¨

Yes, offered fee-based

Yes, offered free 5. The work site regularly provides educational materials/messages that promote healthy living through posters or brochures, promotional campaigns, health fairs, videos, paycheck stuffers, fliers, newsletter articles, and/or routine communication.

¨

Yes, offered fee-based In development

Yes, offered free 4.b. T  o the employees’ family members

No, not offered

¨

Yes, offered free If you chose any of the Yes responses in questions 2.a and/or 2.b, answer question 2.c. If you chose No, not offered, for both 2.a and 2.b, skip to question 3. 2.c. T  he work site evaluates its health promotion programs and seeks feedback. 3. F rontline managers, middle managers, and/ or supervisors actively support employee participation in health promotion activities by allowing them to participate during work hours.

¨

Yes, offered fee-based

No, not offered

¨

1x / yr

¨

< 1x / yr or never

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B. Health promotion (continued) 6. T  he work site informs employees about the ¨ ¨ ¨ ¨ ¨ availability of health promotion programs, services, Always/almost Usually About half Sometimes Rarely/never or classes at the work site, through multiple always 61%–80% 41%–60% 21%–40% 0%–20% communication channels such as newsletters, 81%–100% bulletin boards, postcards, and/or e-mails. 7. T  he work site provides incentives through the ¨ ¨ ¨ health benefits plan or through cash rewards for Yes, both Yes, either No, neither engaging in physical activity and/or healthy eating. benefit plan benefit plan benefit plan and cash or cash nor cash incentives incentives incentives Rate your confidence in your answers for this section:

¨

Very high

C. Physical activity opportunities 1. The work site allows flexible work/ ¨ break time for employees to more easily engage in physical activity.

2. T  he work site conducts or sponsors sports teams, walking clubs, or events to encourage physical activity among employees. 3. T  he work site supports physical activity during meetings (e.g., fun, physically active group work is incorporated in the meeting, and the dress code enables physical activity). 4. Work site management/leaders model the importance of physical activity by participating in group physical activity at meetings or conferences. 5. The work site schedules regular breaks for physical activity (e.g., 5 minutes of each hour, 10 minutes of every two hours, or 15 minutes of every three hours) during meetings and events. 6. T  he work site provides programs or incentives to promote non-motorized/ active commutes to work (e.g., walking, biking, or use of public transportation).

¨

Always/ Usually almost 61%–80% always 81%–100%

¨

¨

¨

¨

¨

¨

Always/ Usually almost 61%–80% always 81%–100% Always/ Usually almost 61%–80% always 81%–100% Always/ Usually almost 61%–80% always 81%–100%

¨

¨

Always/ Usually almost 61%–80% always 81%–100%

¨

¨

High

¨

About half 41%–60%

¨

About half 41%–60%

¨

About half 41%–60%

¨

About half 41%–60%

¨

About half 41%–60%

¨

¨

Medium

Low

¨

Sometimes 21%–40%

¨

Sometimes 21%–40%

¨

Sometimes 21%–40%

¨

Sometimes 21%–40%

¨

Sometimes 21%–40%

¨

Very low

¨

Rarely/ never 0%–20%

¨

Rarely/ never 0%–20%

¨

Rarely/ never 0%–20%

¨

Rarely/ never 0%–20%

¨

N/A

(No group physical activity at meetings)

¨

Rarely/ never 0%–20%

Yes

¨

In development

¨

¨

¨

¨

No

7. The work site has written guidelines or rules or policies related to: 7.a. F lexible work/break time to engage in physical activity

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Yes

In development

No

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C. Physical activity opportunities (continued) 7.b. Active meeting options and regular breaks ¨ ¨ for physical activity during meetings and events

Rate your confidence in your answers for this section:

Yes

¨

Very high

¨

In development

¨

High

¨

Medium

No

¨

¨

Low

Very low

D. Physical environment related to physical activity 1. The work site provides facilities that promote ¨ ¨ physical activity, such as a changing room and/or locker rooms with showers accessible to all employees.

Yes

¨

In development

No

2.The work site provides workout facilities with exercise equipment (or provides access to workout facilities through a subsidized or discounted membership):

2.a. To the employees

¨

¨

Yes, offered free

2.b. To the employees’ family members

¨

4. The work site has stairwells.

¨

Yes

¨

4.a. The stairwells are easy to find, attractive, safe, clean, and accessible (e.g., with light, color, decoration, and safe surfaces). 4.b. T  he use of stairs as an alternative to elevators is promoted (e.g., signage to promote stairwell use). 5. S  ecure bicycle parking is available for employees. Rate your confidence in your answers for this section:

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Everywhere/ almost everywhere 81%–100%

¨

Always/almost always 81%–100%

¨

¨

¨

¨

No No

¨

¨

¨

Usually About half the Some places 61%–80% places 21%–40% 41%–60%

¨

Usually 61%–80%

¨ ¨

No, not offered

In development

¨

About half 41%–60%

¨

Sometimes 21%–40%

¨

Yes, available and secure Very high

¨

Yes, offered fee-based or discounted In development

Yes If you chose Yes in question 4, answer questions 4.a and 4.b. If you chose In development or No, skip to question 5.

No, not offered

¨

Yes, offered free

3. The work site has a safe area outside for exercise (e.g., trails, walking paths, sidewalks).

¨

Yes, offered fee-based or discounted

¨

¨

Medium

¨

Rarely/ never 0%–20%

¨

Available but not secure High

¨

Rarely/ nowhere 0%–20%

No, not available

¨

Low

¨

Very low

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E. Healthy eating opportunities 1. Work site food outlets (e.g., cafeterias, snack bars, vending options, and/or food service) provide healthy eating opportunities to employees in the following ways: 1.a. O  ffering a wide variety of healthy food options on a daily basis, including: • Vegetables and fruits • Whole-grain foods • L ow-fat dairy food (e.g., fat-free or low-fat yogurt or cheese)

• L ow-fat protein items (e.g., lean meat sandwiches, broiled or baked meats, or fish)



• Low-sodium items



• Items containing little or no sugar



• Food items free of trans fat

1.b. Offering healthy beverage options on a daily basis (e.g., water, 100 percent vegetable/fruit juice)

1.c. O  ffering regular moderate serving sizes (i.e., no “super size” portions)

1.d. S  erving any high-fat sauces, salad dressings, gravies, or condiments on the side or offering reduced-fat versions 1.e. U  sing healthy food preparation practices in the cafeteria (e.g., steaming, using low-fat and low-salt ingredients, limited frying) for the majority of menu items

¨

Always/ almost always 81%–100%

¨

Always/ almost always 81%–100%

¨

Always/ almost always 81%–100%

¨

Always/ almost always 81%–100%

¨

Always/ almost always 81%–100%

¨

Usually 61%–80%

¨

Usually 61%–80%

¨

Usually 61%–80%

¨

Usually 61%–80%

¨

Usually 61%–80%

¨

¨

¨

About half 41%–60%

Sometimes 21%–40%

¨

¨

About half 41%–60%

Sometimes 21%–40%

¨

¨

About half 41%–60%

Sometimes 21%–40%

¨

¨

About half 41%–60%

Sometimes 21%–40%

¨

¨

About half 41%–60%

Sometimes 21%–40%

¨

Rarely/ never 0%–20%

¨

Rarely/ never 0%–20%

¨

Rarely/ never 0%–20%

¨

¨

N/A (No food outlets)

¨

N/A (No food outlets)

¨

N/A (No food outlets)

¨

Rarely/ never 0%–20%

N/A (No food outlets)

¨

¨

Rarely/ N/A (No never cafeteria) 0%–20%

2. The work site has written guidelines or rules or policies related to the following: 2.a. O  ffering healthy food options (listed in E.1.a) on-site through the cafeteria, snack bar, vending machines, and/or food service 

Yes

¨

In development

¨

2.b. Offering healthy beverage options (listed in E.1.b) on-site through the cafeteria, snack bar, vending machines, and/or food service

Yes

¨

¨

In development

¨

¨

¨

¨

2.c. P  roviding moderate serving sizes (e.g., no “super size” portions)

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Yes

No

No

In development

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No

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N/A (No food outlets)

¨

N/A (No food outlets)

¨

N/A (No food outlets)

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E. Healthy eating opportunities (continued) 2.d. E  mploying healthy food preparation ¨ ¨ practices in the cafeteria (e.g., steaming, limited frying)

2.e. P  roviding healthy food and beverage choices at companysponsored meetings/events 3. Primarily healthy food and beverage choices (described above in E.1.a and E.1.b) are provided at companysponsored meetings/events. Rate your confidence in your answers for this section:

Yes

In development

¨

¨

Yes

¨

¨

No

¨

¨

High

¨

About half 41%–60%

¨

N/A (No cafeteria)

¨

In development

Always/almost Usually always 61%–80% 81%–100% Very high

¨

No

¨

¨

Sometimes Rarely/never 21%–40% 0%–20%

¨

¨

Medium

Low

¨

Very low

F. Physical environment related to food/nutrition 1. The work site promotes consumption of healthy foods and beverages that are rich in vegetables, fruits, and whole grains and low in fat, sodium, and added sugars at work site food outlets (e.g., cafeterias, snack bars, vending machines, and/or food service) in the following ways: 1.a. P  roviding specific labeling to ¨ ¨ identify healthy options, such Always/ Usually as low-fat foods Note: Labeling almost always 61%–80% refers to messages that have 81%–100% been placed on or near prepared foods or vending machines, not the messages the manufacturer prints on the item itself.

¨

About half 41%–60%

1.b. Providing nutrition information ¨ ¨ for food served on-site (e.g., Always/ Usually food service provides nutrition almost always 61%–80% listings that are placed on tables 81%–100% or in the serving area)

About half 41%–60%

1.c. P  roviding preferred placement ¨ ¨ (e.g., appears sooner in line or in Always/ Usually more prominent positions) and almost always 61%–80% signage that promotes healthier 81%–100% food and beverages

About half 41%–60%

1.d. P  roviding price incentives (e.g., lower prices) for the purchase of healthier food and beverage items

About half 41%–60%

¨

¨

Always/ Usually almost always 61%–80% 81%–100%

¨

¨

¨

¨

¨

¨

¨

¨

¨

¨

¨

Sometimes Rarely/never 21%–40% 0%–20%

Sometimes Rarely/never 21%–40% 0%–20%

Sometimes Rarely/never 21%–40% 0%–20%

Sometimes Rarely/never 21%–40% 0%–20%

¨

N/A (No food outlets)

¨

N/A (No food outlets)

¨

N/A (No food outlets)

¨

N/A (No food outlets)

2. The work site has written guidelines or rules or policies related to: 2.a. Identifying/labeling healthy food and beverage options available at the work site (e.g., low fat)

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Yes

¨

In development

¨ No

¨

N/A (No food outlets) V8

F. Physical environment related to food/nutrition (continued) 2.b. Providing nutrition information ¨ ¨ ¨ for food served in work site food outlets

Yes

In development

No

2.c. P  roviding price incentives for healthier food and beverage options in work site food outlets

Yes

¨

¨

In development

¨

2.d. P  roviding preferred placement and signage to promote healthier food and beverage options in work site food outlets

Yes

¨

¨

In development

¨

¨

2.e. P  roviding nutrition information for food/meals served at events

5. The work site offers an on-site garden or farmers market. 6. The work site offers a clean, private space, with an electrical outlet, for employees to pump/express breast milk or breastfeed babies. Rate your confidence in your answers for this section:

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¨ No

¨

In development

Yes

3. The work site provides nutrition ¨ ¨ information for food/meals served at Always/ Usually events. almost always 61%–80% 81%–100% 4. The work site provides access to a kitchen area with a refrigerator and a sink to enable safe and hygienic handling of healthy food.

No

¨

¨

About half 41%–60%

No

¨

¨

Sometimes Rarely/never 21%–40% 0%–20%

Yes

¨

In development

¨

¨

¨

In development

¨

¨

¨

¨

¨

Very high

¨

¨

Medium

¨

N/A

(No food outlets)

¨

N/A

(No food outlets)

¨

N/A

(No food/ meals served at events)

¨

N/A

(No food/ meals served at events)

No

In development

High

(No food outlets)

No

Yes

Yes

¨

N/A

No

¨

¨

Low

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Very low

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