Wellbeing at Work WHNA Request Form Wellbeing @Work WHNA Request Form Wellbeing @Work WHNA Request Form Thank you for your interest in completing a Workplace Health Needs Assessment (WHNA). Please complete this form fully to allow us to process your request and support you through the process efficiently. On completion of the form, please allow 7 days for one of our team to respond to your request. For more information about the Workplace Health Needs Assessment, please visit: www.lrsport.org/whna. Organisation & Contact Details Organisation & Contact Details Organisation / Workplace Name*: Please select which local authority your workplace is based in:* - Choose - Blaby Charnwood Harborough Hinckley and Bosworth Leicester City Melton North West Leicestershire Oadby and Wigston Rutland My workplace isn't based in Leicestershire, Leicester or Rutland Which sector does your organisation work in?* - Choose - Public Sector Voluntary Sector Private Sector Other How many staff does your organisation employ?* Organisation Address Line 1*: Organisation Address Line 2: Organisation Town/City*: Organisation Postcode*: My organisation is based at more than one location:* - Choose - Yes No Contact Details Contact Details Full Name*: Job Title*: Email Address*: Phone Number*: Mobile Number (optional): Workplace Health Needs Assessment Workplace Health Needs Assessment Please select an approximate date on which you would like to launch your organisation's Workplace Health Needs Assessment:* We recommend having the Workplace Health Needs Assessment open for approximately 4 weeks to allow enough time for employees to complete the survey. Most organisations should aim for a minimum response rate of 40%. However, this is flexible and can depend on the number of staff that your organisation employs. This will be discussed further once your request has been submitted. - 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th 13th 14th 15th 16th 17th 18th 19th 20th 21st 22nd 23rd 24th 25th 26th 27th 28th 29th 30th 31st - January February March April May June July August September October November December - 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 Would you like to include any additional demographic questions? (organisations who employee more than 500 staff only)*: These may include occupational group, department, and working hours, for example shift work. Think carefully about what to include. We can only include additional questions for organisations who employee more than 500 staff. If your organisation is small, employees may feel that giving information, such as their pay grade for example, will identify them. Yes No Not sure Not applicable (organisations who employee less than 500 staff) Please specify the questions you would like to include (organisations who employee more than 500 staff only):
