For more information on worksite wellness resources, please visit:

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1 Introduction The Sonoma County Healthy Business Recognition Program is a voluntary certification program that recognizes employers for developing and implementing exceptional employee wellness programs. Employers are awarded Bronze, Silver or Gold classification based on the breadth and depth of their employee wellness initiatives. A recognized employer is striving to * Be a leader in employee and worksite wellness * Strengthen its bottom line over time by decreasing sick leave, reducing workers compensation claims, and increasing employee productivity * Improve overall employee morale and create an overall healthy workplace * Demonstrate community goodwill To participate in the Sonoma County Healthy Business Recognition Program, please complete the following application. The application was developed based on national and regional wellness standards and reflects the Surgeon General s recommendations for employee health in the 21st Century. For more information on worksite wellness resources, please visit: Important: You will be able to update responses on any page of the survey while you are completing the survey. However, once you exit or complete the survey, you will not be able to go back and make changes to your responses. A project of Health Action s iworkwell Initative in coordination with the Sonoma County Economic Development Board

2 Employer Information 1. Some businesses have multiple sites located throughout Sonoma County and/or in other parts of the state or country. Are you completing this application for a worksite wellness program you have at one site or a program that includes multiple sites? I am completing an application for one site. I am completing an application for multiple sites. 2. Please provide the following information for your business or organization: Employer Street Address City State Zip Code Website Phone Fax 3. Please provide information for the staff person who can contact you should we have any questions: Contact Name Contact Contact Phone 4. Approximately, how many employees work at your business or organization? 5. Please describe your business or organization in 100 words or less Employer Information (Continued) 6. What are the specific goals of your organization as they relate to improving employee wellness? Please check all that apply: Improve productivity Reduce employee health risks (i.e. Cardiovascular Disease) Reduce absenteeism (sick days) Lower worker s compensation/disability costs Other:

3 7. Briefly describe your employee wellness program. 8. What is the approximate cost to your business per year to promote employee wellness: Less than $500 $500 - $1,000 $1,000 - $5,000 More than $5,000 Don t know 9. Approximately what percentage of your employees regularly participate in your employee wellness program? 10. How did you hear about this program? Employee Website Other: Insurance Company Brochure/Postcard 11. Please check the box if you are interested in receiving the following: Periodic electronic newsletters and updates on employee wellness programs and local resources materials that could help your organization develop wellness policies or programs

4 Employee Wellness Program Survey All questions must be completed in order for your employee wellness program score and possible award classification to be determined. 12. Health Promotion Does your worksite provide healthy eating messages (e.g., posters, brochures) and/or community resources (e.g. places to go for health education, smoking cessation classes) to the general employee population? Does your worksite provide physical activity or exercise messages (e.g., posters, brochures) and/or community resources to the general employee population? Does your worksite promote the availability of onsite health promotion programs, such as walking groups or lunchtime speakers, through at least two communication channels (e.g., newsletters, bulletin boards, s, notices with pay stubs)? Does your worksite have a wellness committee or lead employee designated to oversee or champion the wellness efforts at your worksite? Does your worksite have a written policy(s) stating that health promotion programs are provided to the general employee population by your company at your worksite (e.g., smoking cessation classes, weight management classes)? 13. Physical Activity Does your worksite promote individual or group physical activity, such as walking, yoga, stretching or volleyball? Does your worksite promote walking or biking to/from work? Does your worksite have bicycle parking? Does your worksite subsidize memberships to offsite gyms or other fitness programs? Does your worksite allow flex time schedules to encourage employees to include exercise/fitness activities into their workday? Does your worksite have a written policy supporting employee physical activity (e.g., policies that allow workers to take walking breaks, do preheavy-labor stretching, taking time off during lunch to exercise)?

5 14. Healthy Eating For this section, healthy food includes lowfat, reduced sodium, no sugar options such as lowfat or fat free yogurt or cheese, lean meat sandwiches, broiled or baked meats or fish, light or fat free mayonnaise or salad dressing, or whole grain breads. Healthy beverage include lowfat or fat free milk, 100% fruit juice, diet drinks, water, and unsweetened teas and coffees. Does your worksite/break room have one or more microwave ovens or other heating devices for employees? Does your worksite/break room have one or more refrigerators for employees? Does your worksite/break room have at least one sink with a water faucet for employees? Is there a water cooler or filtered water dispenser available to employees free of charge at all times for employees? Does your worksite have a written policy to limit unhealthy food and provide healthy food and beverage options at company meetings, parties, and events; a written policy that limits high-calorie foods employees to sell for fundraisers (e.g., cookies or chocolate for clubs or teams); or a written policy limiting candy jars or other food jars on employees desks, in conference rooms, copy rooms, or waiting rooms? 15. Lactation Accommodation (also known as Breastfeeding Accommodation) Companies successful at retaining valued employees after childbirth find that two components can make the difference: providing dedicated space (as small as 4 x 5 ) for breastfeeding employees to express milk in privacy and providing worksite lactation support. The payoff is significant: more satisfied, loyal employees and cost savings to business. These savings are seen in such areas as: retention of experienced employees, reduction in sick time taken by both moms and dads for children s illnesses, and lower health care and insurance costs. Even support for male employees and their partners can result in lower absenteeism rates among men and lower health insurance claims because the newborns are sick less (Department of Health and Human Services). Does your worksite have a written policy promoting breastfeeding that is communicated to all current employees and included in new employee orientation? Does your worksite provide information and resources to expecting and new parents to encourage breastfeeding?

6 Does your worksite have a private space with an electrical outlet and access to a sink, other than a restroom, for pumping? Does your worksite allow employees 15 minutes or more of break time to express milk during the work day or a flexible work schedule to accommodate pumping? Does your worksite have a refrigerator to store expressed milk? Thank You! Thank you for completing the survey. Someone from the Sonoma County Economic Development Board will contact you within two weeks with your score and possible award classification. If you do not hear from them within two weeks, please call (707) If you have a few minutes, please click "Done" and complete an optional survey about additional employee wellness programs you might have. Again, the survey is optional. Your answers will not be scored.