2016 LiveWell NKY Worksite Application
The LiveWell NKY Worksite Award is a free, voluntary certification designed to recognize and honor worksites that are committed to supporting healthy choices in physical activity, healthy eating and tobacco prevention through policies, programs and environmental changes within their organization. This 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 future strategies to create a healthier workforce.

The LiveWell NKY Worksite Award 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 or gold award level. Recognized worksites will also have access to technical assistance to further improve the health of their work environment that can then help them reach higher recognition levels in the future.

We are excited that your business is taking this opportunity to become a designated 2016 LiveWell NKY Worksite!

Contact and 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) *
What percentage of employees are full-time? *
Does your current health insurance offer wellness benefits to the employees (i.e. Humana Vitality)? *
If a wellness benefits package is offered with insurance, what is the name of the provider?
Is your organization a member of a local LiveWell Community coalition? *
Does your organization share a building or campus with other organizations? *
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 (15 pts.) *
 5 pts. each - 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 (15 pts.) *
5 pts. each - 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/evaluate?
c. Is there a designated employee that attends WW trainings sponsored by Skyward or other affiliated organizations?
How long has your wellness team been in place? (4 pts.) *
Point value depends on length of wellness team in place - select ONE answer
ASSESSMENT (15 pts.) *
Please provide copies of any assessment tools you use, if applicable. 5 pts. each - mark all that apply.
Yes
No
Does your organization conduct an initial employee interest survey to gather baseline data on health needs?
a. Does your organization conduct an annual health/wellness survey with the employees?
b. Does your organization provide annual onsite health screenings (i.e. blood pressure, cholesterol, blood sugar) to employees?
ACTION PLAN (15 pts.) *
Please provide copies of any worksite wellness action plans created, if applicable. 5 pts. each - mark all that apply.
Yes
No
a. Does your organization have a worksite wellness action plan?
b. Does your action plan have a clear mission/vision statement developed for worksite wellness initiatives?
c. 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? (1/2 point each - MAX total 3 pts) *
Health awareness programs are programs that increase the participant level of 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 changing behaviors.
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? (1 point each - Max total 8 pts.) *
Behavior change programs are programs that aim for participants to build the skills necessary to successfully change a less healthy behavior.  The programs provide a goal for participants to work towards, 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 chart, additional education) to help them reach the program goal.
Yes
No
Participation in the NKY Chamber Wellness Challenge
Diabetes Education program
Nutrition education program
Weight management programs (i.e. Weight Watchers)
Tobacco cessation program
Physical activity programs/challenges (i.e. tracking of steps, bootcamps, etc)
Health coaching offered to employees (i.e. through insurance provider)
Offer Employee Assistance Programs (EAP)
If there are any 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? (15 pts.) *
Points accumulate: 1-2 strategies = 5 pts.; 3-4 strategies = 10 pts.; More than 4 strategies = 15 pts
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 yoga)
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? (70 pts.) *
**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) (20 pts.)
Written policy that prohibits indoor tobacco use (5 pts.)
Written policy making healthier foods/beverages available in cafeteria, snack bars or vending machines (15 pts.)
Written policy making healthier foods/beverages available during sponsored meetings where food is served (15 pts.)
Flexible work schedules that would allow employees to add physical activity into their day (walking meetings, encouraging 5-10 minute walk breaks, etc) (15 pts.)
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? (30 pts.) *
Please provide copies of any evaluation tools you use, if applicable. Mark all that apply. Points accumulate: 1 evaluation measure = 5 pts.; 2-3 evaluation measures = 15 pts.; 4 evaluation measures = 30 pts.
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
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.
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