WWKS - Tobacco Assessment

Tobacco Assessment

In developing a comprehensive worksite wellness initiative to address tobacco, five strategies need to be employed: information, program, benefit design, policy, and environment.
Your worksite's individual responses to the survey will not be shared with anyone not affiliated with WorkWell KS. This survey will be used as an assessment to provide worksites with information about the steps your worksite can take to establish a worksite wellness initiative. Only aggregated results (with no worksite identifiers) may be published. If you have any questions regarding this survey, please contact Dr. Elizabeth Ablah at 316-293-2627 (eablah@kumc.edu).
Name of worksite*
Primary contact at worksite*
Contact email*
example@example.com
County*
Zip*
City*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Approximate number of employees
Not counting temporary or seasonal
Approximate number of employee dependents
Spouses and children
What industry type best describes your worksite?

Agriculture, Forestry, Fishing, and HuntingMining, Quarrying and Oil and Gas ExtractionUtilitiesConstructionManufacturingMachinery, Equipment, and Supplies Merchant WholesalersRetail TradeTransportation and WarehousingInformationFinance and InsuranceReal Estate, Rental, and LeasingProfessional, Scientific, and Technical ServicesEducational ServicesHealthcare and Social AssistanceArts, Entertainment, and RecreationAccommodation and Food ServicesGrant Making and Civic OrganizationsPublic Administration (including health departments)Other
Information
In the past 12 months, has your worksite assessed the number of employees who are tobacco users?*

YesNo

Does your worksite inform employees about:*

Rows	Yes	No
Available services and resources for tobacco cessation
Coverage for tobacco cessation treatment (counseling and medication)
The worksite's tobacco-free policy
The consequences of policy non-compliance
How the policy is enforced
How to report violations

Does your worksite promote smoking cessation (a ban on tobacco) inside employees' homes?*

YesNo
Has your worksite conducted an educational campaign (such as posters or graphics) using the Tips From Former Smokers campaign?*

YesNo
Has your worksite conducted an educational campaign (posters, graphics, emails) regarding quitting tobacco other than the Tips from Former Smokers campaign?*

YesNo
1:Calc:Value Scale Total
1:Calc:Score
1:Calc Percent
Campaign/Program

Has your worksite promoted tobacco cessation programs through access to:*

Rows	Yes	No
Counseling
Medication
KanQuit
SmokeFree TXT

Other program (please specify)
Does your worksite encourage tobacco users to combine multiple cessation aids to support their quit attempts (e.g. medications, in-person counsel, phone support)?*

YesNo
2:Value Scale - total
2:Calc:Score
2:Calc Percent
Benefits
Do you promote the tobacco cessation services your health insurance carrier offers?*

YesNo
Does your worksite enforce a health insurance differential for employees that use tobacco compared to non-tobacco users?*

YesNo
Does your worksite provide an employee assistance program (EAP) that includes tobacco cessation counseling for employees?*

YesNo, We have an EAP but not one that includes tobacco cessation counseling for employees.No, we do not have an EAP

Does your worksite's basic benefit plan reduce or eliminate employee out-of-pocket costs for:*

Rows	Eliminate	Reduce	Neither Reduces or Eliminates
FDA-approved prescription cessation medications such as Buproprion (Zyban), varenicline (Chantix), or inhaler or nasal spray nicotine replacement
FDA-approved over-the-counter nicotine replacement products (e.g., gum, patch, lozenge)
Tobacco cessation counseling

3:Calc:Value Scale Total
3:Calc:Score
3:Calc Percent
Policy
Does your worksite have a written tobacco policy?*

YesNo

Select the option that best describes the areas your worksite tobacco-free policy applies to:*

Inside (indoor) company facilitiesAll indoor & outdoor worksite property (parking lots, company vehicles) not including personal vehicles parked on worksite propertyAll indoor & outdoor worksite property (parking lots, company vehicles) including personal vehicles parked on worksite propertyAll indoor & outdoor worksite property (parking lots, company vehicles) including personal vehicles parked on worksite property, and sidewalks, roads, or property that is adjoined to worksite owned or operated propertyOther
Does your worksite enforce the tobacco-free policy restrictions?*

YesNo
4:CalcValue Scale Total
4:Calc:Score
4:Calc Percent
Environment
Has your worksite removed or converted areas that used to be designated for tobacco use into areas for other use not involving tobacco (e.g., covered shelter converted to bike shelter, smoking gazebo converted to garden)?*

YesNoN/A - Worksite never had a designated smoking area
Does any part of your worksite permit the sale of tobacco products on premises (e.g., vending machines, vendors)?*

YesNo

Does your worksite post signs:*

Rows	Yes	No
Stating that smoking is prohibited by state law?
Displaying the international "no smoking" symbol?
Displaying information about the worksite tobacco-free policy?
Displaying that tobacco is prohibited on worksite premises?

5:Calc Value Scale - Total
5:Calc:Score
5:Calc Percent
Should be Empty:

Rows	Yes	No
Cigarettes
Chewing tobacco, snuff, or snus
E-cigarettes or other electronic vaping products
Regular cigars, cigarillos, or little filtered cigars

Tobacco Assessment

Information

Campaign/Program

Benefits

Policy

Environment