North Dakota Well Workplace Award Application 2017

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The North Dakota Worksite Wellness Award is based on evidence-based criteria and best practices that are essential for a successful worksite wellness program.  Each answer has been assigned a point value for the response.  The award requires that some baseline questions are answered in order to receive the award.  If all the baseline requirements are met, then the award level is based on the total number of points received.

This application should be filled out by a wellness committee member or someone directly involved with your organizations wellness efforts.
 

1. Please list name and contact information for the primary contact person for questions regarding this application and your wellness program.
Organizational Information
2. 1.  Organizational Name
3. 2.  Organizational Address (Must be a North Dakota-based worksite)
4. 3.  Has this award application been approved by a key member of your management team?
If yes, list name, title and contact information of the person approving.
If No - STOP - you must have management approval to be eligible for the award