Sample Employee Survey Template

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Attachment 1
SAMPLE EMPLOYEE SURVEY
1. Are you interested in participating in a fitness program?
_____ yes
_____ no
2. If interested, your preference would be: (Number your preferences in order of
importance with “1” being of the most interest to you.)
_____ an off-site fitness center near my home in _____________________
(city/state)
_____ an off-site fitness center near my duty station
_____ a shower/locker room facility at my duty station
_____ a treadmill and basic weight lifting equipment at my duty station
3. Would you be willing to share the cost for membership at an off-site fitness center if
the USGS arranged for a discount of the membership rate or reimbursed you for a portion
of the rate?
_____ yes
_____ no
4. Do you currently belong to a fitness center?
_____ yes
_____ no
5. If so, which one? Name of Center: __________________________________
Location of Center: _______________________________
6. How often do you/would you use a fitness facility?
_____ daily
_____ 1-3 days weekly
_____ other, please explain
__________________________________________________________________
7. Please indicate below the time(s) you would be most likely to participate in a fitness
program. (If you are currently an active member of a fitness center as noted above,
indicate the time(s) you usually go to work out.)
__________________________________________________________________
12

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