Workplace Health Needs Assessment Request Form

Wellbeing @Work WHNA Request Form

Thank you for your interest in completing a Workplace Health Needs Assessment (WHNA). Please complete this form fully to allow us to process your request and support you through the process efficiently. On completion of the form, please allow 7 days for one of our team to respond to your request.

For more information about the Workplace Health Needs Assessment, please visit: www.active-together.org/wellbeingatworkwhna

Organisation & Contact Details

Organisation / Workplace Name*:

Please select which local authority your workplace is based in:*

Which sector does your organisation work in?*

How many staff does your organisation employ?*

Organisation Address Line 1*:

Organisation Address Line 2:

Organisation Town/City*:

Organisation Postcode*:

My organisation is based at more than one location:*

Contact Details

Full Name*:

Job Title*:

Email Address*:

Phone Number*:

Mobile Number (optional):

Workplace Health Needs Assessment

Please select an approximate date on which you would like to launch your organisation's Workplace Health Needs Assessment:*

Important: Please ensure you allow at least 7 days from completing this form for the Wellbeing at Work team to schedule your Workplace Health Needs Assessment.

We recommend having the Workplace Health Needs Assessment open for approximately 4 weeks to allow enough time for employees to complete the survey. Most organisations should aim for a minimum response rate of 40%. However, this is flexible and can depend on the number of staff that your organisation employs. This will be discussed further once your request has been submitted.

Would you like to include any additional demographic questions? (organisations who employee more than 500 staff only)*:

These may include occupational group, department, and working hours, for example shift work. Think carefully about what to include. We can only include additional questions for organisations who employee more than 500 staff. If your organisation is small, employees may feel that giving information, such as their pay grade for example, will identify them.

Yes No Not sure Not applicable (organisations who employee less than 500 staff)

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Workplace Health Needs Assessment Request Form

Wellbeing at Work WHNA Request Form

Wellbeing @Work WHNA Request Form

Organisation & Contact Details

Contact Details

Workplace Health Needs Assessment

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