Employee Physical Activity Survey Template Page 2
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214. In a typical week, do you engage in Physical Activity outside your workplace or outside facility provided/subsidized by
your workplace? This does not include traveling to and from work
Yes
No
14a. If yes, how many days per week do you engage in Physical Activity outside your workplace or outside a facility
provided/subsidized by your workplace? This does not include traveling to and from work. __________ days a week
14b. How much time per day do you usually spend doing Physical Activity outside your workplace or outside a facility
provided/subsidized by your workplace? This does not include traveling to and from work. _____ Hours _____Minutes
15. According to National guidelines, the recommended level of moderate-intensity aerobic activity (i.e., brisk walking)
for adults, per week is: 60 minutes
90 minutes
120 minutes
150 minutes
180 minutes
16. Do you feel that being physically active influences your work? Please describe how:
YES ____________________________________ NO _____________________________________
17. To what extent do you agree or disagree with the following statement: "I believe my workplace is supportive to
Physical Activity". Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
18. The next questions are about your experience at work in the past 4 weeks (28 days) only. Select the one response for
each question that comes closest to your experience. Remember this survey is completely private and anonymous.
There is no way it can be traced back to you. Also, remember that even the hardest workers and most effective employees
aren’t on their game 100% of the time.
a. How often did worry or stress get in the way of your performing your work?
0-10% of the time
10-30% of the time
30-50% of the time
50-80% of the time
80-100% of the time
b. How often did you find it difficult to concentrate on your work?
0-10% of the time
10-30% of the time
30-50% of the time
50-80% of the time
80-100% of the time
c. How often did physical discomfort get in the way of your performing your work?
0-10% of the time
10-30% of the time
30-50% of the time
50-80% of the time
80-100% of the time
d. How many whole days of work have you missed because of problems with your own physical or mental health?
(Please do NOT include days missed because of someone else’s health) ___________ days
e. On how many days have you missed part of the day because of problems with your own physical or mental health?
______ days (If you worked a few hours less than you typically do in any particular day, for example, count that as one
day.)
e. How many whole days of work did you miss for any other reason (vacation included)? __________ days
f. On how many days have you missed part of the day for any other reason (vacation included)? _________ days
20. Please provide your: Height ____________________ & Weight _________________ OR
Decline to state
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Parent category: Life