Employee Physical Activity Survey Template printable pdf download

Employee Physical Activity Survey

Please answer the following questions as best you can. We are committed to safeguarding your privacy and anonymity and this

survey cannot be traced to any individual. If you feel that your answers to any of the questions below might result in your being

identified as the responder to this survey, please feel free not to answer that question.

1. At your work, do you perform manual labor activities that involve manufacturing, construction, auto-mechanics,

maintenance, technical installations, moving, food preparation/serving, cleaning AND/OR activities that require

prolonged standing?

Yes

2. How long have you been working for your current company?

__________

3. How many days a week do you work for your current company?

________

4. How many days a week do you work from home (not at your worksite)?

________

5. How many hours do you work on a typical day?

_________

6. During a typical work day, what proportion (%) of time do you spend in each of the following activities? (This involves

only hours while at work, and does not include travel to and from work, or what you do in your leisure time).

a. Sitting

________

b. Standing

______

c. Walking

_______

TOTAL ___________ % (Make sure this adds up to 100%)

7. On a typical work day, how many breaks from sitting (such as standing up, or stretching or taking a short walk) during

one hour of sitting would you typically take at work?

5 or more

8. On a typical work day, how many times do you take the stairs (at least 10 steps) at work? __

_____

9. On average, how many flights of stairs do you climb up at work on a typical work day? (One flight = 10 steps) ______

10. Approximately how many miles is it from your home to your workplace? ________

11. In a typical work week, how many times do you travel from your home to your workplace?

_________

12. On a typical work day, what is the total time that you spend using the following modes of transportation to and

from work? Please indicate all forms of transportation that you use.

(e.g., If you walk to the train station, indicate how long it takes

you to get there, also how long you take on public transit -please make sure you enter total time for round trip.)

Biking:

Hours _____ Minutes _____

Walking:

Hours _____ Minutes _____

Vehicle:

Hours _____ Minutes _____

Public/company transport: Hours _____ Minutes _____

13. In a typical week, do you engage in Physical Activity at your workplace or at a facility provided/subsidized by your

workplace? (E.g.:weight training, jogging, sports, stretching, group exercise)

Yes

13a. If yes, how many days per week do you engage in Physical Activity at your workplace or at a facility

provided/subsidized by your workplace? __________ days a week

13b. How much time per day do you usually spend doing Physical Activity at your workplace or at a facility

provided/subsidized by your workplace? _____ Hours _____Minutes

Employee Physical Activity Survey Template

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