The Small Business Health Model - A Guide to Developing and Implementing the Workplace Health System in Small Business

Appendix 2: Readiness Profile

Please take the time to complete this profile. It will help organizers determine if there is enough community support to begin the Small Business Health Model.

1. General information

Name _________________________________________

Phone Bus _____________________________________

Phone Res _____________________________________

Organization/business ___________________________

Mailing address ________________________________

Postal Code ___________________________________

Describe the nature of your organization/business
______________________________________________

2. Individual involvement

Listed below are some of the possible areas of responsibility and functions of the Small Business Health Model organizing groups, (the Coordinating Agency and Small Business Health Committee). Please indicate which areas you would like to be involved in. (Indicate preference 1, 2, 3).

• Administration
• Finance/Fund raising
• Promotion
• Program development
• Program support/volunteer
• Facilities/equipment
• Resources (health promotion)
• Registration
• Other (please specify)
• In what capacity would you like to be involved?
• Chair a group (two meetings a month)
• Serve on a committee (one or two meetings a month)
• Committee secretary
• A volunteer for specific events or programs
• Last-minute volunteer
• Program participant
• Other (please specify)

3. Meeting time preference

The best day(s) for me are:

The best time of day is:

I cannot attend meetings at the following times on the days I have noted:

4. Would your organization/business be interested in a commitment to the Small Business Health Model in one of the following ways?

• Encourage employee access to health promotion programs
• Provide meeting space for the organization
• Sponsor a health promotion workshop
• Encourage health promotion programs at the workplace
• Sponsor a speaker
• Provide food and beverages for program activities
• Financial assistance
• Provide secretarial/clerical services
• Other (please specify)

5. Please list other individuals or organizations/businesses you think might be interested in assisting with a Small Business Health Model project, or who would like to receive information.

Name ____________________________________________
Organization/business ______________________________
Phone ___________________________________________

Name ____________________________________________
Organization/business ______________________________
Phone ___________________________________________

Name ____________________________________________
Organization/business ______________________________
Phone ___________________________________________

6. Do you have ideas or expertise that could benefit the project that have not been covered? If so, please elaborate.

7. How do you think this program can assist you, your employees, your business?

Thank you for taking the time to complete this questionnaire. We will communicate its results to you as soon as possible.