YourWorkpath Program: Pre Program/Interest Form Survey

You are receiving this survey Tool and Toolkits survey from the Oregon Institute of Occupational Health Sciences and Oregon Healthy Workforce Center at OHSU. We appreciate your interest in our resources that promote the improvement of workplace safety, health and well-being. Responses help us gather information on your interest in one of our tools and toolkits. Your participation is highly valued and greatly appreciated. Your information will be kept private and never shared externally, unless permission is requested and approved. If you have any questions or concerns, please contact Helen Schuckers (Dissemination Specialist) at schucker@ohsu.edu.

Date*

Name of Organization*

Are you a new contact or existing contact*

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What Industry is your organization in?*

Check all that apply

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What is the size of your organization?*

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Name of Contact*

(Format: Helen Schuckers)

What is the best email and phone number to reach out to?*

(email, phone)

Are you in a supervisor/manager/ team lead role?*

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Are you a health/safety practitioner?*

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Have you heard of Total Worker Health?*

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What type of safety, health, and well-being programs and resources do you currently have within your organization and/or specific department? Please explain*

What type of safety, health, and well-being tools or programs would you like to bring into your organization?*

Do you currently have resources allocated to implement safety, health and well-being programs or tools within your organization?*

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Do you have a team or committee dedicated to advocate and implement safety, health and well-being tools, resources or programs? If so, what team or committee is designated to make these decisions?*

Have you conducted a survey, evaluation or needs assessment on what outcomes need to be improved in your workplace? Please explain*

What motivates your company to implement a safety, health or well-being program?*

Do you perceive/rate your organization to have low, average, or above average injury rates, employee well-being, and employee health. Please explain.

What is your organization's main goal or objective for adopting a safety, health, and well-being tools and/or program? (check all that apply)*

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Would you like to implement a safety, health, well-being across an entire organization or within a specific department? Please explain.*

Approximately how many people does your organization plan to distribute the tool and/or toolkit to? Please include numerical value.*

How will you promote or recruit participants to use safety, health and well-being tools and toolkits within your organization?*

As part of the Workpath program, we will produce a written Total Worker Health case study report featuring your organization, and in some cases a short video or podcast. Which do you prefer?*

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What resources and/or information did you receive to learn about our tools and toolkits? (Check all that apply)*

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Would like to stay in touch for future partnership, research or dissemination opportunities?*

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Which safety, health and well-being tools are you interested in? (check all that apply).

For more information, visit our tools page at www.YourWorkpath.com/Tools

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Which safety, health and well-being toolkit or intervention are you interested in? (Check all that apply)

For more information on our toolkits, please visit our toolkit page at www.YourWorkpath.com/toolkits

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Send me a copy of my responses

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