Workplace Environmental Assessment
Please complete the following assessment and return to the Department of Health. Please send to

Are you completing this assessment for your whole agency or a specific site? Agency Site

Agency name: Site name (if applicable):

Agency or site location:

Is the agency a State Executive Branch Agency that is required to implement the Healthy Nutrition Guidelines through Executive Order
13-06? Yes No

Application completed by (name and position):

Contact information email: phone:

Assessment

1.  Total number of people employed (full-time or part-time) at your agency, organization, or site

2.  Total number of worksites/locations

§  If more than one, do your other sites plan to apply for recognition?

Yes No Unsure

3.  Does your agency or organization have a wellness team? Yes No

§  If yes, please include name and contact information for the wellness coordinator

§  Will your wellness coordinator or team be responsible for implementing the Healthy Nutrition Guidelines?

Yes No – If no, who will be?

4.  Has your agency adopted a healthy food and beverage service policy? Yes No

§  If yes, please remember to send a copy to the Department of Health at

§  If no, see our model policies at www.doh.wa.gov/choosewell-livewell

5.  Which guidelines apply to your agency, organization, or site? (Select all that apply)

Guideline Area / Who will be responsible for implementing the Guidelines? (list name and position, if different from wellness coordinator) / Total number of machines, cafeterias, institutions, etc.
Vending
Cafeterias, cafés, and on-site retail
Meetings and events / N/A
Institutional Food Service

6.  VENDING QUESTIONS:

§  What is the name of your vending company?

§  How many slots do your vending machines have?

§  Please take a picture of your vending machine(s) and submit with this assessment before beginning implementation.

7.  CAFETERIA QUESTIONS:

§  Please list the names and locations for all of your cafeterias, cafés, and onsite retails:

8.  Does your agency or organization plan to apply for recognition for implementing the Guidelines?
Yes No Not yet decided

9.  Is your agency participating in Washington Wellness’ Team WorkWell? If yes, remember that your participation in Choose Well-Live Well counts to the Team WorkWell Zo 8 Award!
Yes No Not yet decided


Thank you for completing the Workplace Environmental Assessment! Please remember to complete the Implementation Tools for Cafeterias and Institutions, if applicable!