ĐĎॹá>ţ˙ ’ţ˙˙˙Œ“˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙ěĽÁ#` đż0dbjbjmĽmĽ 4nĎĎ $˙˙˙˙˙˙¤    đđđŒQŒQŒQŒQ$°QtŤq.0R(XRXRXRXR7SŚÝSD!T$vpxpxpxpxpxpxp$ŮrhAuœpÉđxX3S7SxXxXœp  XRXRŰeq&]&]&]xX4 8XRđXRvp&]xXvp&]&]ŞmäŘđĘoXR$R đ¸éhČŒQŹX0ňnRp${q0ŤqoĆvÜY.v$ĘoĘovđŢotETć+U¤&]ĎU„SV%ETETETœpœp ]ETETETŤqxXxXxXxXd&h+$&h+      ˙˙˙˙ Premier’s Award for Healthy Workplaces Overview The Premier’s Award for Healthy Workplaces is designed to recognize employers in Alberta that provide strategies, initiatives, policies and / or programs (hereafter referred to a “healthy workplace initiatives”) that promote, support and enhance a healthy workplace and the efforts of workers to remain healthy at work and beyond. These must include (but are not limited to) both physical activity or active living and healthy eating components. A single, isolated health education or health promotion activity does not constitute a healthy workplace initiative for these awards. Application Process Complete appropriate application form depending on the size of your workplace. Application includes: Cover Page Background Information Checklist Short Answers Promotional example Sign-off sheet Mail completed application and an electronic copy (on disk or by e-mail) by 4:00 p.m. on December 14, 2007. Selection Committee reviews applications. Information identifying your workplace will be blanked out by program staff in order to facilitate an unbiased review process. Award recipients are selected. All applicants are notified of the outcome for their workplace. Award luncheon – two representatives from each workplace receiving an award will be invited to attend at no expense to the employer. Mail applications to: Premier’s Award for Healthy Workplaces Attn: Regina Beckett Population Health Strategies Branch Alberta Health and Wellness 23rd Floor, Telus Plaza North Tower 10025 Jasper Avenue Edmonton, Alberta T5J 1S6 E-mail questions or the electronic copy of your application to:  HYPERLINK "mailto:premiersaward@gov.ab.ca" premiersaward@gov.ab.ca Contact Alberta Health and Wellness 780 415 2754 with questions. Toll-free, call 310-0000. Application forms are available online at  HYPERLINK "http://www.healthyalberta.com/premiersaward" www.healthyalberta.com/premiersaward Application for Premier’s Award for Healthy Workplaces Medium, Intermediate or Large Workplaces COVER PAGE Organization Name: Number of Employees in Alberta-based workplaces: Contact: Name: Title: Telephone #: Fax #: E-mail address: Media Contact: Name: Title: Telephone #: Fax #: E-mail address: Date of application submission: Office Use Only Date Application Received: Application includes: Background information Ą% Checklist Ą% Short Answers Ą% Promotional Material Ą% Received: Sign-off Ą% Application #: Received by: Signature:  I. BACKGROUND INFORMATION Organization name: Number of employees in Alberta: Ą% Medium: 100-499 Ą% Intermediate: 500-999 Ą% Large: 1000 or more Mailing Address of Organization: Contact Person: Name: Title: Telephone #: Fax #: E-mail address: Alternate contact person: Name: Title: Telephone #: Fax #: E-mail address: Number of sites covered by this application: Type of workplace: Name of Owner/ Executive Director/ Principal : Webpage (if applicable): How did you hear about the Premier’s Award for Healthy Workplaces: Ą% Applied last year Ą% Newspaper Ą% Magazine (please specify) ________________________ Ą% News Ą% e-mail Ą% Colleague Ą% Other (please specify) ________________________ II. CHECKLIST 1. What areas does your healthy workplace initiative address? How? Please check all that apply. a. Physical Activity/Active Living: Ą% Yes Ą% No Ą% Programs Ą% Special Events Ą% Information Ą% Evaluation Ą% Policy Ą% On site facility Ą% On site locker rooms and showers Ą% Bicycle Racks Ą% Subsidy for outside facility / program Is there a charge for participants? Ą% Yes Ą% No If yes, please elaborate ___________________________________ ____________________________________________________ b. Healthy Eating: Ą% Yes Ą% No Ą% Programs Ą% Special Events Ą% Information Ą% Evaluation Ą% Policy Ą% Healthy choices in cafeteria and vending machines Ą% Healthy choices at meetings Is there a charge for participants? Ą% Yes Ą% No If yes, please elaborate ___________________________________ ____________________________________________________ c. Smoking Cessation: Ą% Yes Ą% No Ą% Programs Ą% Special Events Ą% Information Ą% Evaluation Ą% Policy Is there a charge for participants? Ą% Yes Ą% No If yes, please elaborate ___________________________________ ____________________________________________________ d. Stress Management: Ą% Yes Ą% No Ą% Programs Ą% Special Events Ą% Information Ą% Evaluation Ą% Policy Is there a charge for participants? Ą% Yes Ą% No If yes, please elaborate ___________________________________ ____________________________________________________ e. Occupational Health and Safety: Ą% Yes Ą% No Ą% Programs Ą% Special Events Ą% Information Ą% Evaluation Ą% Policy Ą% Department Is there a charge for participants? Ą% Yes Ą% No If yes, please elaborate ___________________________________ ____________________________________________________ f._____________________: Ą% Programs Ą% Special Events Ą% Information Ą% Evaluation Ą% Policy Is there a charge for participants? Ą% Yes Ą% No If yes, please elaborate ___________________________________ ____________________________________________________ g._____________________: Ą% Programs Ą% Special Events Ą% Information Ą% Evaluation Ą% Policy Is there a charge for participants? Ą% Yes Ą% No If yes, please elaborate ___________________________________ ____________________________________________________ h._____________________: Ą% Programs Ą% Special Events Ą% Information Ą% Evaluation Ą% Policy Is there a charge for participants? Ą% Yes Ą% No If yes, please elaborate ___________________________________ ____________________________________________________ CHECKLIST (continued) 2. Promotion How are your healthy workplace initiatives promoted to your employees? (Please check all that apply) Posters Displays/Bulletin Boards Pamphlets E-mails Intranet Supervisors/Senior Management Newsletters Orientation Corporate manuals Other: ______________ 3. Evaluation a. 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Ą% Yes Ą% No How regularly to you evaluate your healthy workplace initiatives by consulting with employees? Ą% Weekly Ą% Monthly Ą% Quarterly Ą% Annually Have you made changes to your healthy workplace initiatives based on evaluation feedback? Ą% Yes Ą% No Have you seen any changes as a result of your healthy workplace initiatives? Ą% Yes Ą% No III. SHORT ANSWERS Answers exceeding the outlined word limited with not be considered. All answers should be in 12-point Arial font. When (what year) and how did your healthy workplace initiative begin? 100 words Give 3 bullet points stating the three objectives of your healthy workplace initiative. (Eg. To decrease absenteeism) 25 words per bullet What is the vision and mission of your organization and your wellness program? Provide an organizational chart and circle where your healthy workplace initiative fits. Please describe the involvement of your senior management. 100 words Profile 3-5 different elements of your healthy workplace initiative. Physical activity and healthy eating must be profiled as 2 of the elements. 100 words per element Describe the impact that your healthy workplace initiative has had on your workplace. How has the program changed your workplace? 200 words What evidence do you have that your program has made a difference. Please include any data that you have collected to show change. (Please provide evidence, e.g. 20% reduction in absenteeism, or 30% increase in healthy choices sold in cafeteria.) 400 words Profile one employee who has significantly impacted your healthy workplace initiative. This employee could be a participant and/or an organizer. They should exemplify your program. 200 words Highlight a successful program or event that you are most proud of. It should be innovative and have had a large impact with employees. 250 words Is there anything else about your healthy workplace initiative you have not yet had an opportunity to highlight in the application? Please do so here. 250 words IV. PROMOTIONAL MATERIAL Please attach or mail one piece of promotional material from your healthy workplace initiative. For example, this could be a brochure, e-mail, or poster and should include any branding that is affiliated with your program. Also attach an organization logo which may be used for media, the website and the award ceremony. V. DISCLAIMER Alberta Health and Wellness reserves the right to publish submission details, in accordance with the Alberta Freedom of Information and Protection of Privacy (FOIPP) Act. Workplaces should expect to receive provincial attention following receipt of this award. Materials provided may be used for the media, the website and at the award luncheon to highlight your program. V. SIGN OFF BY OWNER/EXECUTIVE DIRECTOR/PRINCIPAL I, _______________, hereby indicate that the information provided for the Premier s Award for Healthy Workplaces is accurate. 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