ࡱ> y  /bjbj 0{{ '0000L0s40j3j3j33333333$79|4j3H3"j3j3j34X-4333j3"33j33333pb73 33C40s43I;3I;3I;3Hj3j33j3j3j3j3j3443j3j3j3s4j3j3j3j3I;j3j3j3j3j3j3j3j3j3 : Appendix A  American Cancer Society HealthLinks Washington Employer Practices Survey Organization: Respondent(s): Date: _______  The survey were doing today addresses prevention of cancer and other chronic diseases at the workplace. The questions correspond to best practices that affect key health behaviors like tobacco use, physical activity, nutrition, and cancer screening. There are five sections in the survey: Health Insurance Benefits, Workplace Policies, Employee Programs, Tracking, and Communication. Health Insurance Benefits This first section is about this organizations health insurance benefits. What is the name of the health plan that most of the employees subscribe to? _______ For these questions, please answer about the current benefits with this health plan. Lets begin. For this first set of questions, please answer yes or no. QuestionYesNo1Does this organization pay for at least 50% of the total cost of personal health insurance for all full time employees? FORMCHECKBOX 1 FORMCHECKBOX 02Does this organization pay for at least 50% of the total cost for family coverage of all full time employees? FORMCHECKBOX 1 FORMCHECKBOX 0 Do you have control over the benefit design for that plan? Yes____ No_____ If yes, proceed to next question on the survey. If no, proceed to Workplace Policies section of the survey on page 2. For the next set of questions, there will be three answer choices. For each preventive care service I list, please tell me whether it is covered in this organizations primary health plan with no out-of-pocket expense, or covered with an out-of-pocket expense, or not covered at all. By out-of-pocket expense, I mean a co-pay, co-insurance, or deductible the employee is required to pay. Preventive ServiceCovered with no out of pocket expenseCovered with an out-of-pocket expenseNot Covered 3aBreast cancer screening, or mammogram FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 33bCervical cancer screening, or Pap smear test FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 33cColon cancer screening, such as colonoscopy or the fecal occult blood test FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 33dPrescription smoking cessation medication, such as Zyban, Wellbutrin, and Chantix FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 33eOver-the-counter nicotine replacement therapy, including nicotine patch, lozenges, and gum FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 33fFace-to-face tobacco cessation counseling, including group and individual counseling FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 Workplace Policies The second section is about the organizations workplace policies. The questions are about tobacco, physical activity, nutrition, and sun protection. For most of the questions in this section, please answer yes or no. For these questions, its important that we discuss only policies that affect most of this organizations employees. Please answer yes to a question only if it applies to at least 75% of the organizations employees. If a policy affects less than 75% of the employees, please answer no. First, I will read two statements describing tobacco use policies. Please tell me which one most closely describes this organizations current policy. 4Employees are allowed to use tobacco on the premises, including in vehicles, but not inside the building. FORMCHECKBOX 1Employees and visitors are banned from using any form of tobacco throughout the premises, including company grounds and vehicles.  FORMCHECKBOX 2 QuestionYesNo5Does this organization have any written policy restricting employee tobacco use?  FORMCHECKBOX 1 FORMCHECKBOX 0If yes, go to #6. If no, go to #7.6Does this organization have enforcement procedures for its policy on tobacco use? FORMCHECKBOX 1 FORMCHECKBOX 07Does this organization provide food on-site, such as cafeterias or vending machines?   FORMCHECKBOX 1  FORMCHECKBOX 0If yes, go to #8. If no, go to #10.8Are healthy food choices available on-site, such as fruit, vegetables, or low-calorie foods?  FORMCHECKBOX 1 FORMCHECKBOX 0If yes, go to #9. If no, go to #10.9Are healthy food choices subsidized or priced competitively? FORMCHECKBOX 1 FORMCHECKBOX 010Does this organization label healthy food choices, or post any nutritional content about healthy food choices? FORMCHECKBOX 1 FORMCHECKBOX 011Is there an organizational policy stating healthy foods will be provided at meetings and other employee events? FORMCHECKBOX 1 FORMCHECKBOX 012Does this organization provide access to physical activity facilities, such as walking trails or fitness areas, on-site or nearby?  FORMCHECKBOX 1 FORMCHECKBOX 013Has this organization posted "take the stairs" signs near elevators and stairwells? Not Applicable  FORMCHECKBOX  FORMCHECKBOX 1 FORMCHECKBOX 014Has this organization negotiated discounts or financial incentives for employees to join commercial fitness centers? FORMCHECKBOX 1 FORMCHECKBOX 015Do any of this organizations employees work primarily outdoors? FORMCHECKBOX 1 FORMCHECKBOX 0If yes, go to #16. If no, go to #18.16Does this organization have a policy requiring employees to use sun protection, such as sunscreen or protective clothing, if they are exposed to sun while on the job?  FORMCHECKBOX 1 FORMCHECKBOX 017Does this organization provide sunscreen or protective clothing for outdoor workers? FORMCHECKBOX 1 FORMCHECKBOX 0 Employee Programs This third section is about this organizations health programs. These are programs that the organization offers, or contracts with a vendor to offer to employees. These are separate from insurance benefits. The questions will be about programs for tobacco cessation and physical activity. Again, please answer yes only if at least 75% of employees have access to the program. QuestionYesNo18Does your organization contract with an outside vendor to provide an employee telephone tobacco cessation counseling program, or quitline? FORMCHECKBOX 1 FORMCHECKBOX 0If yes, go to #19. If no, go to #21. 19Does the telephone counseling service provide nicotine replacement therapy? FORMCHECKBOX 1 FORMCHECKBOX 0If yes, go to #20. If no, go to #21.20Is there any out-of-pocket expense for the nicotine replacement therapy? FORMCHECKBOX 1 FORMCHECKBOX 021In the past year, has your company organized or sponsored an employee physical activity program? FORMCHECKBOX 1 FORMCHECKBOX 0If yes, go to #22. If no, go to #25.22Does the program allow participants to set their own physical activity goals? FORMCHECKBOX 1 FORMCHECKBOX 023Is the physical activity program group-based? FORMCHECKBOX 1 FORMCHECKBOX 024Does the program offer incentives to participate? FORMCHECKBOX 1 FORMCHECKBOX 0Tracking The fourth section is about employee health surveys and other activities that your organization may conduct in order to measure and track health-related issues among your employees. QuestionYesNo25Has your organization conducted an employee health risk appraisal or surveyed employees about health risk behaviors, or contracted with a vendor to do this? FORMCHECKBOX 1 FORMCHECKBOX 0If yes, go to #26. If no, go to #27.26About what percentage of all employees completed the survey?_____%Communication The last section is about health promotion and communication. By this I mean your organizations efforts to communicate with employees specifically about health, such as health status, health behaviors, or chronic disease prevention. This could be anything from a newsletter or email to an organized campaign or group event. These are communications outside of health insurance open enrollment periods or insurance provider communications. QuestionYesNo27Does your organization communicate with employees about health at least four times a year? FORMCHECKBOX 1 FORMCHECKBOX 0 28 Does your organization make any health-related materials regularly available to employees, such as newsletters, pamphlets, or websites? FORMCHECKBOX 1 FORMCHECKBOX 0 29 Does your organization provide health topic informational sessions, such as lunch-and-learn presentations, to your employees? FORMCHECKBOX 1 FORMCHECKBOX 0 30 Does your organization promote the WA state-sponsored tobacco cessation quitline among employees? FORMCHECKBOX 1 FORMCHECKBOX 0 31 Does your organization promote the WA-state breast and cervical cancer program among employees? FORMCHECKBOX 1 FORMCHECKBOX 0 Now, I will list some methods for communicating with employees. For each one, please tell me if you use this method to communicate with employees about health issues. ItemYesNo32aWebsite FORMCHECKBOX 1 FORMCHECKBOX 032bEmail  FORMCHECKBOX 1 FORMCHECKBOX 032cNewsletters  FORMCHECKBOX 1 FORMCHECKBOX 032dBulletin boards FORMCHECKBOX 1 FORMCHECKBOX 032ePayroll stuffers FORMCHECKBOX 1 FORMCHECKBOX 032fMailings to employees homes FORMCHECKBOX 1 FORMCHECKBOX 032gMeetings FORMCHECKBOX 1 FORMCHECKBOX 032hOther(s): Now I will list some health behaviors. For each one, please answer yes if this organization has communicated with employees about the health behavior in the past year.ItemYesNo33aTobacco cessation FORMCHECKBOX 1 FORMCHECKBOX 033bNutrition FORMCHECKBOX 1 FORMCHECKBOX 033cPhysical activity FORMCHECKBOX 1 FORMCHECKBOX 033dCancer screening FORMCHECKBOX 1 FORMCHECKBOX 033eSun Protection FORMCHECKBOX 1 FORMCHECKBOX 033fOther(s):  Thank you for taking this survey!    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