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Survey Response Form:

Are you an employer looking for a problem-solving resource to improve your organizations productivity?

Complete this online survey, and help us understand your needs.

Please provide the following information:

First Name
Middle Initial
Last Name
Street Address
Address (cont.)
Zip/Postal Code
Work Phone

Position: Please choose one of the following:

Organization has an EAP?

Yes No

Name of Vendor:

If yes, how long has EAP been in place?    Years


Rate satisfaction with current EAP. On scale of 1 (lowest) - 5 (highest)

1   2   3   4  

Offer Short Term Disability?

Yes No

Offer Long Term Disability?

Yes No

If yes, describe involvement in managing disability cases (to assure development and implementation of appropriate return to work plans)

Use broker or consultant?

Yes No

If yes, name of broker/consultant

Health & EAP Resources, Inc.
Copyright 2000. All rights reserved.
Revised: June 12, 2006