Wellness Award

IMPORTANT: The form does not save your responses during input. Please have all your answers saved in a Word document then copy and paste your answers into the form.
Have you been an employer in Canada for the last five years or more?
Do you have more than 20 employees?
Are you willing to administer an employee perception survey provided by the Canada’s Safest Employers organizing committee to your workforce should you be shortlisted? (See FAQ section for details.)
Note: If you answered No to any of the questions above, you are not eligible to participate in the selection process for Canada’s Safest Employers Awards.
In the last five years, has your company been charged under occupational health and safety, workers' compensation and/or the Criminal Code legislation? (If yes, please give details)
In the last five years, has your company been convicted under the occupational health and safety, workers' compensation and/or the Criminal Code legislation? (If yes, please explain.)
In the last five years, have you incurred any workplace fatalities? (If yes, please explain)
Contact information
Employer name
Mailing address
Postal code
Contact person (Person responsible for this application)
E-mail address
Telephone number
Alternate contact name
E-mail address
Telephone number
About the organization
Brief description of the organization / scope of operations.
Employee profile
Total number of employees
Please note that each question has a 7,000 character maximum.
Do you have an Employee Assistance Program? (2 points)
Name of EAP plan provider?
Please list the items covered in your EAP.
Do you offer a smoking cessation plan? (2)
Do you offer flu shot clinics? (2)
Do you offer diabetes awareness and/or screening programs? (2)
Do you offer heart health awareness and/or screening sessions? (3)
Do you offer healthy lifestyle sessions / seminars? (5)
Do you offer stress reduction initiatives? (5)
List health and wellness-­related services available through a company plan, such as massage therapist, chiropractor, naturopath. (5)
Are your workstations ergonomic? (5)
How do you educate staff on ergonomics?
Do employees have access to a nutritionist? (2)
Do you have an onsite cafeteria and/or are healthy food options available/encouraged? (5):
If yes, are healthy alternatives subsidized by the company? (2)
Do your vending machines offer healthy food choices? (2)
Do you offer a subsidy or personal spending account for gym memberships or sporting equipment? (3)
If yes, how much per employee per year?
Do you do anything to encourage employees to bike to work? (2)
Do you have a lunchtime walking club or incentives to encourage employees to take walks during breaks? (3)
List any work-­life balance initiatives. (5)
Does your organization or staff participate in community health and wellness events? (3)
How do you promote your wellness program and encourage employee participation? (3)
Do you have a mental health component to your wellness programming? (3)
How does your return to work program support employee well-being? (3)
Do you have a strategy for measuring the effectiveness of your wellness programs? (5)
How does senior management support your wellness strategy? (8)
Please list other initiatives or wellness goals at your organization. (15)
Injury statistics in the last three years (5 points)
Lost time injury frequency rate


Statement of Truth
  1. I'm the person named in, and who subscribed in, this application form for Canada's Safest Employers. To the best of my knowledge and belief, the matters and facts in it are true. Where matters specifically stated in it are made upon information and belief, I believe them to be true. I make this declaration conscientiously believing it to be true and knowing that it is of the same force and effects as if made under oath.
  2. I understand if my company is a gold winner we need to participate in a phone interview with a journalist as well as an on-site video shoot. I understand I am not able to see the article or the video prior to publication as they are both pieces of journalism, not personalized marketing items.

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