Department Name
Contact Name
Campus Address
Campus Extension
Campus Email

1. Indicate the size of your department
   1. 1-50
   2. 51-100
   3. 100+
       
2. Screenings. Check the screenings/evaluations and preventive programs that apply to your department. (Check all that apply.)
   1. Encourages employees to complete the online Health Assessment through the Priority Health website as part of the Thrive @ GVSU program.
   2. Encourages employees to participate in the Thrive @ GVSU program.
   3. Faculty and staff are allowed to claim sick leave or flex time in order to participate in Thrive @ GVSU administered by Priority Health.
   4. Faculty and Staff are allowed to claim sick leave or flex time in order to get a physical exam, mammogram, or other preventive exam.
   5. Other:___________________________________
       
3. Percentage of employees in your department who participated in Thrive @ GVSU in the last 12 months.
   1. 0-10%
   2. 11-25%
   3. 26-50%
   4. 51-75%
   5. 76-100%
       
4. Physical Activity. Check the physical activity programs that apply to your department. (Check all that apply.)
   1. Flexible work schedules to allow faculty and staff time for physical activity.
   2. Encourages faculty and staff to take advantage of the University-paid membership to the Fieldhouse Recreation Center/Winter Hall Fitness Room or YMCA and area gym discounts.
   3. Hosts walk-and-talk meetings.
   4. Supports physical activity breaks during the workday, such as stretching or walking.
   5. Supports department-based fitness challenges.
   6. Supports departmental walking clubs.
   7. Schedules in-service training for faculty and staff on benefits and guidelines for physical activity.
   8. We offer ergonomic desk alternatives (i.e., stability balls, sit-to-stand desks, walking workstations).
   9. Other:_____________________
       
5. Nutrition. Check the nutrition programs that apply to your department. (Check all that apply.)
   1. Requests healthy options for vending machines
   2. Provides healthy options at all meetings and conferences.
   3. Provides protected time and dedicated space away from work area for breaks and lunch.
   4. Faculty and staff are allowed to claim sick leave or flex time for consultations with a Registered Dietitian.
   5. Schedules in-service training for faculty and staff on nutrition information.
   6. Encourages faculty and staff to attend cooking demonstrations.
   7. Encourages faculty and staff to attend nutrition classes/sessions provided by Human Resources or Campus Recreation.
   8. Faculty and staff in our department have easy access to a break room with a refrigerator, microwave and/or toaster oven.
   9. Other:__________________________
       
6. Emotional Health and Stress Management. Check the emotional health and stress management programs that apply to your department. (Check all that apply.)
   1. Flexible work schedules to allow faculty and staff to attend or participate in emotional health programs offered on campus offered through Work Life Connections.
   2. Flexible work schedules for faculty and staff in caregiving situations. 
   3. Faculty and staff are allowed to claim sick leave for medical appointments related to emotional health.
   4. Unit heads, deans and supervisors attend Mental Health First Aid training to help understand emotional health issues and better assist faculty and staff. 
   5. Promotes and encourage faculty and staff to utilize GVSU’s Employee Assistance Program, Encompass.
   6. Promotes stress management through “quiet rooms”, on-site relaxation classes, proper lighting, sound reduction measures or other techniques.
   7. Faculty and staff are encouraged to resolve conflict in the workplace through mediation services and/or the GVSU Conflict Resolution Process.
   8. Other:______________________________________________
       
7. Tobacco Use. Check the tobacco use programs that apply to your department. (Check all that apply.)
   1. Promotes the Tobacco Free for Good free programs and services or other tobacco cessation programs to faculty and staff who currently use tobacco products.
   2. Flexible work schedules to allow faculty and staff to attend smoking cessation classes.
   3. Other:_______________________________
       
8. Emergency Medical Response Plan. Check the emergency medical response plan programs that apply to your department. (Check all that apply.)
   1. Has a written plan for emergency response to medical events within the department.
   2. Provides CPR training to faculty and staff within the department.
   3. Other:___________________________________
       
9. Health and Wellness Ambassador. Check below if you have a Health and Wellness Ambassador in your department. This person relays health and wellness information to departmental faculty and staff, and assists the department with its own wellness goals and initiatives.
   1. Yes
   2. No
       
10. Other programs. List other health-related programs that your department offers that are not listed above.