Exhibit # by ccp35665


									           Exhibit 4
                   Wellness Program Pre-Planning Checklist

       City                                                 Wellness Coordinator


1. Previous Wellness Activity
   What wellness activities have you offered in the past? Examples of activities are health screenings,
   smoke-free workplace policy, seat belt policy, employee assistance program, fitness activities, health
   club memberships, classes on stress management, smoking cessation back injury prevention,
   nutrition, weight management, disease prevention, etc.

   What were the results?

2. City Interest
   Describe your city’s interested in starting an employee wellness program?

3. Employee Count by Worksite
   List all city worksites and the approximate number of employees at each location. If employees are
   required to work various shifts, please indicate employee count by shift for each location (D – days, S –
   swing, and G – graveyard).
                        Worksite Location                              Number of Employees
                                                               D                S              G
                                                               D                S              G
                                                               D                S              G
                                                               D                S              G
                                                               D                S              G
                                                               D                S              G
   Total Number of Employees                                   D                S              G

   The following are key components of successful wellness programs. You may not be able to answer all
   the questions at this time. They are included in this pre-planning checklist to help you to begin to think
   about the areas involved in putting together a program and to identify the areas that will need attention in
   the planning stage.

4. City Support:
   What do you think is the current level of support for a wellness program?
                          Very High          High        Moderate         Low            None
   Elected Officials
   Top Management

                                                                                  Chapter 3 Wellness Planner 47
      Do you think you will need assistance in generating support?
            Yes         What type of assistance would be helpful?
            Don't know

5. Employee Committee:
      Have you used employee committees for projects or problem-solving in the past?
            What was your experience?

      Would you consider using an employee committee for the wellness program?
            Don't know

6. Financial Resources:
      Describe your financial resources for wellness: (Check all that apply)
            No Budget
            Low budget
            Adequate funding available
            Will use AWC financial assistance programs
            Don't know at this time.

7. Staff Time:
      Use the following as a general guideline.
      Program set-up: 20 - 40 hours
      Meeting time during first year: (2) hours per month
      Responsibilities between meetings during first year: 2-4 hours per member

      Will the coordinator and committee members have adequate time to design and implement
      your wellness program?

8. Employee Needs and Interest Survey*:
      Would you consider using an employee interest survey* to help in planning the activities of the
      wellness program?
     * AWC Wellness Program will provide a sample employee needs and interest survey that can be used “as
     is” or revised by the city.

9. Communication:
      How do you currently inform employees of activities or policies (e.g. e-mail, bulletin boards,
      newsletters, staff meetings)?

      What other methods of communication would work in your work setting?

48      Association of Washington Cities
10. Program Resources:
  What city resources are available to use for your program? Don't assume resources are or are not
  available for your committee's use. ASK!

  Internal Human Resources:
                        Yes       No      Resource        Name          Phone         E-mail Address

   Health Professional



   Communications Staff

   Marketing Person

   Graphic Artist


   Print Shop Personnel

   Resources Staff

   Risk Management

   Talented Co-Workers

   Movers and Shakers

   Peer Leaders


   Safety Officer

   Healthy Roll Model

   Employee Assistance
   Program Staff

                                                                             Chapter 3 Wellness Planner 49
     Internal Material Resources:
                                             Yes   No   Resource   Notes
     Committee Meeting Space

     Office Space

     Class/Activity Space

     On-site Showers, Locker Room

     On-site Exercise Facilities

     Lunch room/Break room Facilities

     Vending Machines

     Health Clinic

     Payroll Insert System

     Employee Newsletter

     Voice Mail
     Bulletin Boards
     Desk Top Publishing

     Copy Machine (black and white, color)

     Audio Equipment
     Overhead Projector

     Flip Charts

     DVD Player
     Recreational Leagues or Clubs

     Safety Committee

     Regularly Scheduled Safety Meetings
     Safety Regulations for Certifications

     Smoking Policy

     Continuing Education Budget
     Employee Assistance Program
     Employee Training Program

     Employee Recognition Program

50     Association of Washington Cities
11. Incentives:
    Do you plan to use participation incentives with your program?

12. Timing:
    Has your city implemented other new programs within the last twelve months?

    If yes, which ones, and what were the employees' reactions?

    Are you ready to start a wellness program?

    If you answered yes, contact the AWC Wellness Works staff at (800) 562-8981 to discuss the next steps.
    Members of the AWC Employee Benefit Trust receive free personal consultations with AWC staff
    members who will help you get started. We offer a full line of programs and services to give you support
    every step of the way.

If you are planning to apply for the AWC Wellness Program Incentive, please make a copy of this completed
checklist and submit it with your application.

Revised 3/06

                                                                               Chapter 3 Wellness Planner 51
52   Association of Washington Cities

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