Submission Date

Employer Profile

Employer Name:

For-ProfitNot-For-Profit

Number of Employees (Thurston County):

Industry/Type of Business:

# of Work sites/Offices (Thurston County):

Employer Address

Street:

City:

Zip:

Employer Phone:

Employer Fax:

Website Address:

Employer Mailing Address (if different from above):

Street:

City:

Zip:

Contact Information

Contact Name for Application

First Name:

Last Name:

Contact Title:

Contact Phone:

Contact Email:

Owner/CEO/Head of Organization Information

Name of Owner/CEO/Head of Organization

First Name:

Last Name:

Email for Owner/CEO/Head of Organization:

Your Story

The questions below provide an opportunity to tell the story of how you, as an employer, made a commitment to the health of your workforce during 2011.

Response Required for Bronze, Silver, and Gold Designation

How did your organization provide ‘support’ for changes to the work environment or culture in 2011 that impacted or have the potential to impact healthy eating and physical activity among your employees?

Response required to ONE of the following for Silver Designation, or TWO or more for Gold Designation. Please include a brief description of the results anticipated or achieved due to your efforts.

What specific changes were made to the work environment or culture in 2011, that made ‘healthier food’ choices available or more accessible to employees?

What specific changes were made to the work environment or culture in 2011, that made engaging in ‘physical activity’ during work hours an option or easier choice for employees?

What specific changes were made to the work environment or culture in 2011, that made engaging in ‘Life Balance Activities’ during work hours an option or easier choice for employees?

Happy Heart Achievement Recognition Awards - Optional

Are there other policies, programs or activities, undertaken by your organization in 2011, to support employee health and fitness that could be considered when our committee selects Happy Heart Achievement Awards?

Please make sure that all information you have entered is correct.
We will send you and the "Owner/CEO/Head of Organization", an email copy of the information that you have entered on this form