CDC Employee Health Assessment (CAPTURE) TM
HEALTHY WORKSITE HEALTHY WORKFORCE HEALTHY COMMUNITYHEALTHY WORKSITE HEALTHY WORKFORCE HEALTHY COMMUNITCDC Employee Health Assessment(CAPTURE )
CDC National Healthy Worksite Program (NHWP)Employee Health Assessment (CAPTURETM)IntroductionThis survey asks about your current health status, health behaviors, readiness to change your health behaviors, yourneeds and interests related to worksite health and safety, and questions about how your health may impact your work.NOTE: Below is informed consent language and survey instructions that you can adapt for use in your own workplacehealth programs. This information is intended to be a reference and offers suggested wording similar to that found inCDC consent forms included those in the National Healthy Worksite Program.Informed ConsentBefore you get started, we need to give you some more information to help you decide whether or not you would like toparticipate. Your participation in this survey is voluntary. In the course of this survey, you may refuse to answer specificquestions. You may also choose to end the survey at any time. The survey is designed to take about 30 minutes. There are no right or wrong answers or ideas—we want to hear about YOUR experiences and opinions. All of the comments you provide will be maintained in a secure manner. We will not disclose your responses oranything about you unless we are compelled by law. Your responses will be combined with other information wereceive and reported in the aggregate as feedback from the group. Your name will not be linked to any responses you provide in this survey. There are no personal risks or personal benefits to you for participating in this survey.When you have completed this survey, please seal it in the envelope provided, and place it in one of the collection boxeslocated throughout your work site by [INSERT DATE], or give it to [INSERT WORKSITE PROGRAM MANAGER].If you have any questions, please feel free to contact [INSERT WORKSITE PROGRAM MANAGER]. [HIS/HER] number is[INSERT TEL #].1Modified for Public Use
The Employee Health Assessment (CAPTURE) tool has modified Question #43 from the Brown University Rapid Eatingand Activity Assessment for Patients (REAP) tool and received permission to use it in the CDC National Healthy WorksiteProgram (NHWP).Permission to use, copy, and distribute the REAP and REAP provider key for an educational purpose (other than itsincorporation into a commercial product) is hereby granted without fee, provided that the below copyright noticeappear in all copies and that both that copyright notice and this permission notice appear in the materials, and that thename of Brown University not be used in advertising or publicity pertaining to distribution of the materials withoutspecific, written prior permission. Any adaptation or modification of the REAP tools must receive prior approval fromBrown University.Copyright 2005, Institute for Community Health Promotion, Brown University, Providence, RI. All Rights Reserved.BROWN UNIVERSITY DISCLAIMS ALL WARRANTIES WITH REGARD TO THESE MATERIALS, INCLUDING ALL IMPLIEDWARRANTIES OF MERCHANTABILITY AND FITNESS FOR ANY PARTICULAR PURPOSE. IN NO EVENT SHALL BROWNUNIVERSITY BE LIABLE FOR ANY SPECIAL, INDIRECT OR CONSEQUENTIAL DAMAGES OR ANY DAMAGES WHATSOEVERRESULTING FROM LOSS OF USE, DATA OR PROFITS, WHETHER IN AN ACTION OF CONTRACT, NEGLIGENCE OR OTHERTORTIOUS ACTION, ARISING OUT OF OR IN CONNECTION WITH THE USE OR PERFORMANCE OF THESE MATERIALS.This work was supported by Contract #: 200-2011-42034 from the Centers for Disease Control and Prevention. Itscontents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers forDisease Control and Prevention, the Department of Health and Human Services, or the U.S. government.2Modified for Public Use
InstructionsTo make sure that health-related information and programs are tailored to your health concerns, we areasking each employee to fill out this survey. DO NOT write your name on this survey. Please write in blackor blue ink only. Thank you for your participation.Participant IdentificationDo Not Write Here.Health Status1Would you say that in general your health is?(Source: BRFSS) Excellent Very good Good Fair Poor Don’t know/not sure2Have you ever been told by a doctor, nurse orother health professional that you have any ofthe following disorders (check all that apply): Heart disease (heart attack, angina, bypass) Atrial fibrillation or flutter Congestive heart failure Heart valve disease or murmur Other vascular disease (PAD, PVD,aneurysm) High blood pressure Borderline hypertension orpre-hypertension High blood cholesterol Diabetes Elevated blood sugar, borderline diabetes,gestational diabetes or pre-diabetes Chronic obstructive pulmonary disease(COPD), emphysema or chronic bronchitis Asthma Arthritis, rheumatoid arthritis, gout, lupusor fibromyalgia Carpal tunnel syndrome Chronic or recurrent low back pain A depressive disorder (includingdepression, major depression, dysthymia orminor depression)3Modified for Public Use
Health Status3Are you currently taking medicine for any ofthe following conditions? High blood pressure Asthma High blood cholesterol Arthritis Diabetes Low back pain4Do you take aspirin daily? (Source: BRFSS) Yes No5In the past three months, have you had muscle,skeletal or joint pain, achiness or stiffness inany of the following areas every day for a weekor more? Neck or shoulders Low back Elbow, wrist or hand Hip, knee, ankle or foot6If yes to question 11, how often does this pain,aching or stiffness affect you or your activities? Rarely Monthly Weekly Daily NeverQuestion 7 is for women only. Men skip to question 8.7Are you pregnant or considering becomingpregnant within the next year? (women only) Yes No Don’t know/not sure4Modified for Public Use
Preventive Services8About how long has it been since you lastvisited a doctor for a routine checkup? (Aroutine checkup is a general physical exam,not an exam for a specific injury, illness orcondition). Within past year (less than 12 months ago) Within past 2 years (1 year but less than 2years ago) Within past 5 years (2 years but less than 5years ago) 5 or more years ago Don’t know/not sure NeverThe next set of questions asks about preventive services you may have received and when youhad them last.9Blood pressure check Within past year (anytime less than12 months ago) More than 12 months ago Don’t know/not sure Never10Cholesterol test Within past year (less than 12 months ago) Within past 2 years (1 year but less than 2years ago) Within past 5 years (2 years but less than 5years ago) 5 or more years ago Don’t know/not sure Never11Have you had a test for high blood sugar ordiabetes within the past three years? Yes No Don’t know/not sure12Sigmoidoscopy and colonoscopy are exams inwhich a tube is inserted in the rectum to viewthe colon for signs of cancer or other healthproblems. Have you ever had either of theseexams? (Source: BRFSS)For a SIGMOIDOSCOPY, a flexible tube isinserted into the rectum to look forproblems. A COLONOSCOPY is similar,but uses a longer tube, and you are usuallygiven medication through a needle in your armto make you sleepy and told to have someoneelse drive you home after the test. Was yourMOST RECENT exam a sigmoidoscopy or acolonoscopy? (Source: BRFSS) Yes No [Skip to Question #15] Don’t know/not sure13 Sigmoidoscopy Colonoscopy Don’t know/not sure5Modified for Public Use
14How long has it been since you had your lastsigmoidoscopy or colonoscopy?(Source: BRFSS) Within past year (anytime less than12 months ago) Within past 2 years (1 year but less than 2years ago) Within past 3 years (2 years but less than 5years ago) Within past 5 years (3 years but less than 5years ago) Within past 10 years (5 years but less than10 years ago) 10 or more years ago Don’t know/not sure15During the past 12 months, have you hadeither a seasonal flu shot or a seasonal fluvaccine that was sprayed in your nose?(Source: BRFSS) Yes No Don’t know/not sureQuestions 16 – 19 are for women only. Men skip to question 20.16A mammogram is an x-ray of each breast tolook for breast cancer. Have you ever had amammogram? (Source: BRFSS) Yes No [Skip to Question #18] Don’t know/not sure[Skip to Question #18]17How long has it been since you had your lastmammogram? (Source: BRFSS) Within past year (anytime less than12 months ago) Within past 2 years (1 year but less than2 years ago) Within past 3 years (2 years but less than5 years ago) Within past 5 years (3 years but less than5 years ago) 5 or more years ago Don’t know/not sure Never18A Pap test is a test for cancer of the cervix.Have you ever had a Pap test? (Source: BRFSS) Yes No [Skip to Question #20] Don’t know/not sure[Skip to Question #20]6Modified for Public Use
19How long has it been since you had your lastPap test? (Source: BRFSS) Within past year (less than 12 months ago) Within past 2 years (1 year but less than2 years ago) Within past 3 years (2 years but less than5 years ago) Within past 5 years (3 years but less than5 years ago) 5 or more years ago Don’t know/not sureLifestyle Yes No [Skip to Question #24] Don’t know/not sure Every day Some days Not at all [Skip to Question #23]20Have you smoked at least 100 cigarettes inyour entire life? (Source: BRFSS)21Do you now smoke cigarettes every day,some days or not at all? (Source: BRFSS)22During the past 12 months, have you stopped Yes [Skip to Question #24]smoking for one day or longer because you No [Skip to Question #24]were trying to quit smoking? (Source: BRFSS) Don’t know/not sure [Skip to Question #24]23How long has it been since you last smoked a Within the past month (less than 1 month ago)cigarette, even one or two puffs? Within the past 3 months(Source: BRFSS)(1 month but less than three months ago) Within the past 6 months (3 monthsbut less than 6 months ago) Within past year (6 months but less than 1year ago) Within past 5 years (1 year but less than 5years ago) Within past 10 years (5 years but less than10 years ago) 10 years or more Don’t know/not sureDo you currently use chewing tobacco, snuff, Every dayor snus every day, some days or not at all? Some daysSnus (rhymes with ‘goose’) Not at all(Source: BRFSS)During the past month, other than your Yesregular job, did you participate in any No [Skip to Question #32]physical activities or exercises such as Don’t know/not surerunning, calisthenics, golf, gardening or[Skip to Question #32]walking for exercise? (Source: BRFSS)24257Modified for Public Use
Consider what type of physical activity or exercise you spent the most time doing during thepast month. (See Appendix A on page 15 for examples.)262728How many times did you take part in thistimesactivity during the past month? (Source: BRFSS) Don’t know/not sureAnd when you took part in this activity, for howminutesmany minutes did you usually keep Don’t know/not sureat it? (Source: BRFSS)When you took part in these activities, how Low (can sing a song)intense was your exercise session? Moderate (can carry on a conversation)(Source: BRFSS) High (can only say short sentences) Very high (winded/single words only)Now consider what other type of physical activity gave you the NEXT MOST exercise duringthe past month. (Skip to question 32 if no additional physical activity).29How many times did you take part in this timesactivity during the past month? (Source: BRFSS) Don’t know/not sure30And when you took part in this activity, for howminutesmany minutes did you usually keep Don’t know/not sureat it? (Source: BRFSS)When you took part in these activities, how Low (can sing a song)intense was your exercise session? Moderate (can carry on a conversation)(Source: BRFSS) High (can only say short sentences) Very high (winded/single words only)3132How often do you use seats belts when youdrive or ride in a car? Would you say ?(Source: BRFSS)33During the past 30 days, how many days perweek or per month did you have at least onedrink of any alcoholic beverage such as beer,wine, a malt beverage or liquor?(Source: BRFSS) Always Nearly always Sometimes Seldom Never Don’t know/not sure days per weekor days in past 30 days No drinks in past 30 days Don‘t know/not sure8Modified for Public Use
3435363738394041One drink is equivalent to a 12-ounce beer, a5-ounce glass of wine or a drink with one shotof liquor. During the past 30 days, about howmany drinks did you drink on average? NOTE: a40-ounce beer would count as three drinks, ora cocktail with two shots would count as twodrinks. (Source: BRFSS)Considering all types of alcoholicbeverages, how many times during the past 30days did you have five (men) or four (women)or more drinks on an occasion? (Source: BRFSS)During the past 30 days, what is the largestnumber of drinks you had on any occasion?(Source: BRFSS)During the past 30 days, how many times perweek did you eat fried foods? (Fried chicken orfish, hash browns, french fries, etc.)(Source: REAP. Copyright 2005, Institute forCommunity Health Promotion, BrownUniversity, Providence, RI. All rights reserved)During the past 30 days, not counting juice,how many times per week did you eat fruit?Count fresh, frozen or canned fruit.(Source: BRFSS)During the past 30 days, how many times perweek did you eat vegetables not including let tuce salads, potatoes, cooked dried bean(Include any form of the vegetable – raw,cooked, canned, or frozen)? EXAMPLES includetomatoes, green beans, carrots, corn, cabbage,bean sprouts, collard greens and broccoli.(Source: NHANES)During the past 30 days, how many timesper week did you eat whole grain foods(whole-wheat grains or pasta, oatmeal)?(Source: NHANES)During the past 30 days, how many times perweek did you drink regular soda or pop thatcontains sugar? Do not include diet soda ordiet pop. (Source: BRFSS)drinks Don’t know/not suretimes None Don’t know/not suredrink(s) Don’t know/not suretimes per week Don’t know/nnot suretimes per week Don’t know/not suretimes per week Don’t know/not sureper week Don’t know/not sureper week Don’t know/not sure9Modified for Public Use
Mental Well-being4243Over the last two weeks, how many days haveyou had trouble falling asleep OR stayingasleep OR sleeping too much?(Source: BRFSS)How often do you get enough restful sleep tofunction well in your job and personal life? of days (0-14 days) None Don’t know/not sure Always Most of the time Sometimes Rarely Never Don’t know/not sure44How often do you experience stress at WORKthat exceeds your ability to cope? Always Most of the time Sometimes Rarely Never Don’t know/not sure45How often do you experience stress at HOMEthat exceeds your ability to cope? Always Most of the time Sometimes Rarely Never Don’t know/not sure46How often do you get the emotional and social Alwayssupport you need? Most of the time(Source: BRFSS) Sometimes Rarely Never Don’t know/not sureOver the last two weeks, how many days haveof days (0-14 days)you felt down, depressed or hopeless? None(Source: BRFSS) Don’t know/not sureOver the last two weeks, how many days haveof days (0-14 days)you had little interest or pleasure in doing Nonethings? (Source: BRFSS) Don’t know/not sureDo you ever think of hurting yourself? Yes No Don’t know/not sure47484950Now thinking about your physical health,which includes physical illness and injury, forhow many days during the past 30 days wasyour physical health not good?of days (0-30 days)10Modified for Public Use
5152Now thinking about your mental health, whichincludes stress, depression and problems withemotions, for how many days during the past30 days was your mental health not good?(Source: BRFSS)of days (0-30 days)During the past 30 days, for about how manydays did your poor physical or mental healthkeep you from doing your usual activities suchas self-care, work, or recreation?(Source: BRFSS)of days (0-30 days)Which of the following best describes you regarding each of these activities?(For each question check the option that best applies to you.)I amsatisfiedwith theway I amnow andhave nodesire tochangeI haveconsideredmakinghealthierchoicesI haveseriouslyconsideredmakinghealthierchoices andI am readyto make achangeI havestartedmakinghealthierchoicesI haveNot sure/already made Don’t knowchanges fora healthierlifestyle andI am tryingto maintainthem53HealthyEating 54WeightLoss 55Physicalactivity 56TobaccoUse 57StressReduction Sleep AlcoholUse 585911Modified for Public Use
Wellness OpportunitiesWhich of the following health topics would you like information on, if available?Q# “yes” or “no” for all thatQuestionResponse(Checkapply.)YesNo 60Nutrition/healthy eating61Weight management6263Onsite fitness/physical activityopportunitiesWalking group64Cholesterol reduction65Blood pressure reduction66Diabetes awareness and management67Men’s health issues68Reducing risk of heart disease or stroke69Pre-pregnancy planning70Women’s health issues71Back/neck pain management7273Anxiety/depression awareness andmanagementHow to quit tobacco74Managing stress75Medical self-care7677Ergonomics (work station or computerset-up, proper lifting, etc.)Personal financial management78Allergy and asthma management79Safe sex80We will offer 10-15 minute individual healthcoaching sessions on a variety of wellnesstopics. If you attended, when would it be bestfor you? Immediately before my workday begins During my break(s) Immediately after my workday ends During my workday81How much time during your workday are youable to dedicate to worksite wellness activities? Less than 10 minutes 10-20 minutes 21-30 minutes 31-40 minutes 41-50 minutes 51-60 minutes Don’t know/not sure12Modified for Public Use
Work-related Health HistoryTo what extent do you agree with the following statements?82After work I have enough energy for leisureactivities. Strongly Agree Agree Neutral Disagree Strongly Disagree83More and more often, I talk about my work in anegative way. Strongly Agree Agree Neutral Disagree Strongly Disagree84At work, I often feel emotionally drained. Strongly Agree Agree Neutral Disagree Strongly Disagree85In the past 30 days, I had a hard time doing mywork beacuse of my health. Strongly Agree Agree Neutral Disagree Strongly Disagree86In the past 30 days, my health kept me fromconcentrating on my work. Strongly Agree Agree Neutral Disagree Strongly DisagreeIn the following questions, consider how much work you have missed because of healthproblems and how many times you’ve been injured on the job.87888990In the past 30 days, how many times did youmiss part or all of a workday for any reason?timesIn the past 30 days, how many times did youmiss a half day of work because of problemswith your physical or mental health?timesIn the past 30 days, how many times did youmiss a full day of work because of problemswith your physical or mental health?timesIn the past 12 months, how many times haveyou been injured on the job?13Modified for Public Usetimes
References1. Segal-Isaacson CJ, Wylie-Rosett J, Gans KM. Validation of a short dietary assessment questionnaire: theRapid Eating and Activity Assessment for Participants short version (REAP-S). Diabetes Educ. 2004Sep-Oct;30(5):774, 776, 778 passim. PubMed PMID: 15510530.2. Gans KM, Risica PM, Wylie-Rosett J, Ross EM, Strolla LO, McMurray J, Eaton CB. Development andevaluation of the nutrition component of the Rapid Eating and Activity Assessment for Patients (REAP):a new tool for primary care providers. J Nutr Educ Behav. 2006 Sep-Oct;38(5):286-92. PubMed PMID:16966049.3. Gans KM, R
Employee Health Assessment (CAPTURE TM) Introduction This survey asks about your current health status, health behaviors, readiness to change your health behaviors, your needs and interests related to worksite health and safety, and questions about how your health may impact your work.
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Strategies for Reducing Health Disparities Selected CDC-Sponsored Interventions August 31, 2016 Karen Bouye, PhD, MPH, MS Office of Minority Health and Health Equity (CDC) . States, 2016. For more information, contact CDC 1-800-CDC-INFO (232-4636) TTY: 1-888-232-6348 www.cdc.gov
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CDC, Dr. Mae Melvin, 1977 . Malaria: Utah Public Health Disease Investigation Plan Page 3 of 10 09/24/2015 . Detailed recommendations for preventing malaria are available 24 hours a day from the CDC Malaria Hotline, which can be accessed by telephone at 770-488-7788, by fax at 888-CDC-FAXX or 888-232-3299, or on the CDC website at www.cdc.gov .
Prof. Andreas Wagner Karlsruhe Institute of Technology (KIT) Published: April 2014 Third edition: May 2015 2. The significance of thermal insulation Arguments aimed at overcoming misunderstandings 3. 4 Preamble. The energy renovation of existing build-ings represents a key component of the “Energiewende” (energy revolution). The building envelope and the system technology used within the .
