Corporate Wellness Assessment
CORPORATE INFORMATION
Email address *
Company Name *
Your answer
Contact Person *
Your answer
Job Title *
Your answer
Address *
Your answer
Telephone *
Your answer
Email *
Your answer
Have you ever had a corporate wellness profile established for your company? *
Corporate Wellness Profile
By answering the following questions, Lavoro can attain information on your company to better provide our services.
*All company information will remain confidential.
Number of Employees *
Your answer
Number of Locations *
Any Offshore or Remote Locations *
Gender Breakdown
Please give an accurate ratio of your workforce in terms of gender. (See next question)
Total Employees: Male/Female *
Your answer
Age Group Breakdown
Please give an accurate number of your workforce in terms of age. (See next question)
How many employees <18 years of age?
How many employees 18-34 years of age?
How many employees 35-44 years of age?
How many employees 45-64 years of age?
How many employees ≥65 years of age?
Age Group Totals *
Your answer
Racial/Ethnic Breakdown (optional)
Please give an accurate ratio of your workforce in terms of racial/ethnicity. (See next question)
How many employees are Non-Hispanic White?
How many employees are Non-Hispanic Black/African American?
How many employees are Hispanic/Latino?
How many employees are Asian/Asian American?
How many employees are American Indian/Alaska native?
How many employees are Native Hawaiian/Pacific Islander?
Racial/Ethnic Totals *
Your answer
Work Status Breakdown
Please give an accurate ratio of your workforce in terms of work status. (See next question)
How many employees are Full-time?
How many employees are Part-time?
How many employees are Temporary?
Work Status Totals *
Your answer
Job Type Breakdown
Please give an accurate ratio of your workforce in terms of job type. (See next question)
How many employees perform Office Work?
How many employees perform Manual Labor?
Job Type Ratio (% / %) *
Your answer
Shift Type Breakdown
Please give an accurate ratio of your workforce in terms of shift type. (See next question)
Work performed is typically Day
Work performed is typically Night
Work performed is typically Shift work
Shift Types Ratio (% / %) *
Your answer
Educational Level Breakdown
Please give an accurate ratio of your workforce in terms of educational level. (See next question)
How many employees have Less than high school education?
How many employees have High school graduate/GED?
How many employees have Some college/technical school?
How many employees have bachelors degrees?
How many employees have post-graduate/advanced degrees?
Educational Level Breakdown (% / %) *
Your answer
Industry Type *
Health Insurance coverage provided to employees? *
Who is your insurance provider?
Your answer
Does your insurance provider provide discounts on wellness services or programs? *
Is your organization self-insured? *
Does your company include references to improving or maintaining employee health in the business objectives or organizational mission statement? *
Does your organization demonstrate employee health commitment and support of at all levels of employment through the policies, strategies, and or programs? *
Explain your commitment. *
Your answer
Name any other health, safety, or environmental programs within your organization. *
Your answer
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