F.I.T.

Tool 2: Healthy Workplace Self-Assessment Tool

Overview:

F.I.T.-ool 2 is the Self-Assessment Tool that aids the Management/Administration/HR in identifying health gaps that require
improvements within the workplace. It has 7 types based on the 7 Priority Areas (PAs) and is designed as a self-administered
questionnaire in relation to the 5 actionable areas. This tool serves as the basis or guide in planning for the improvements to be
undertaken within the workplace. This document has three (3) parts, namely 1) Background Information, 2) Self-Assessment Proper,
and 3) Interpretation of Results and Recommendations.

Part 1. Background Information

Instructions: Write the appropriate information in the blanks provided. Place a checkmark on items marked with ( ).

A. Name of Company: Municipal Health Office – Currimao

B. Name of Person Filling-out this Document: Dr. Addielou Fidelfio E. Abad

C. Address : Poblacion 1, Currimao, Ilocos Norte

D. Company Contact Information:

a. Telephone Numbers: 0919-075-8867
b. Email Address: [email protected]
c. Organization Type: () Government/Public ( ) Private
d. Industry Type: (Based on the 2009 Philippine Standard Industrial Classification, 2019 Updates)
( ) Agriculture, Forestry and Fishing ( ) Mining and Quarrying
( ) Manufacturing ( ) Electricity, Gas, Steam and Air-Conditioning Supply
( ) Water Supply, Sewerage, Waste Management ( ) Construction
( ) Wholesale and Retail Trade; Repair of ( ) Transportation and Storage Motor Vehicles and Motorcycles
( ) Accommodation and Food Service Activities ( ) Information and Communication
( ) Financial and Insurance Activities ( ) Real Estate Activities
( ) Professional, Scientific and Technical Services ( ) Administrative and Support Service Activities
( ) Public Administrative and Defense; ( ) Education Compulsory Social Security
( ) Human Health and Social Work Activities ( ) Arts, Entertainment and Recreation
 ( ) Other Service Activities ( ) Activities of Private Households as Employers
( ) Activities of Extraterritorial Organizations and Undifferentiated Goods and Services and Bodies Producing
Activities of Households for Own Use

E. Total number of workers (includes management and staff): 20

Part 2. Self-Assessment Proper

A. Self-Assessment Proper (Priority Areas vis a vis Areas of Influence)

Description:
Part 2 is where the respondents score the current workplace status in view of the 7 Priority Areas. Note that this Part has 7 sections,
identified as Priority Areas 1 - 7; and each area is to be scored accordingly. This part has 5 columns headed as (A) - Action Area, (B) -
Indicator, (C)- Guide to Scoring, (D)- Actual Scores and (E)- Comments/Justifications.

Priority Area 1 DIET and PHYSICAL ACTIVITY

Action Area Indicator Guide to Scoring Score Comments/Means
(0-2) of Verification

(A) (B) (C) (D) (E)

1. Developing 1. The workplace has a Minimum Standard: ● Signed Policy from

Healthy Public workplace policy promoting Management and
Policy healthy diet and physical activity Score - 2 Workers
in the workplace ● The workplace has
disseminated an issuance
related to the promotion of ● Mode of
healthy diet and physical dissemination
activity within the
workplace.
 ● There are organized (Seminar/forum/em
Advocates/Volunteer ail/online, etc)
Groups or Teams
promoting healthy
Diet and Physical Activity in
the workplace. ● List of workers
who are Advocates
or members of
Groups/Volunteer
groups/teams
promoting a
Score -1 healthy diet and
● Presence of one of the above physical activity
Score -0
● none at all

2. Creating a 1. The workplace provides the Minimum Standard: ● Number of

Supportive needed facilities/equipment or workers accessing
Environment privileges to support the Score – 2 facilities/equipment
promotion of healthy diet and ● 80% of workers have to promote healthy
physical activity in the access to facilities/equipment diet and physical
workplace. in activities out of the
support to the promotion of Total number of
healthy diet and physical workers
activity in the workplace (Records/Logbooks
Attendance sheet/
DPO/ etc)

● There is an issued
policy (or its
equivalent) that

● Management provides or
 allows privileged time for
workers participating in

healthy diet and physical allows privileged

activities Time to workers on
their participation
to advocacy
activities for the
promotion of
healthy diet and
physical activities

● Number of
workers who have
been
allowed privileges
(e.g. privileged
time) for their
participation in
promoting healthy
diet and physical
activities out of the
Score -1 total no. of
● Presence of one of the above workers. (Company
Score – order/DPO,
● none at all certificate of
privileged time,
etc.)

3. Developing 1. The workplace provides Minimum Standard:

Personal Skills training and personal skills Score – 2 ● List of training or
development related to the ● Provision of training orientation
promotion of diet and physical opportunities related to courses
activity in the workplace. healthy diet and physical related to healthy
activity by management. diet and physical

● Minimum of 50% of activities allowed

workers availed the allowed by Management for
training attendance of
or orientation related to workers
healthy diet and physical
● Number of workers
activity
who availed of
the
allowed training or
orientation related
to healthy diet and
physical
activity/Total
Number of Workers

Score - 1
● Presence of one of the above

Score – 0
● None at all

4. 1. The workplace actively Minimum Standard:

Strengthening supports and participates in LGU Score – 2 ● Number of workers
Community led or community-hosted ● 50% of workers actively who actively
Action projects/activities related to support or participate in participate/support
healthy diet and physical LGU-led or community LGU-led or
activity. hosted projects/activities community-hosted
related to healthy diet and activities related to
physical activity. healthy diet and
physical
activity/Total
Number of workers

● LGU-led, community-hosted ● List of LGU-led or

activities supported by the community-hosted
workplace (monetary and activities supported
non-monetary support) by the company
(monetary and non
monetary

Score – 1
● Presence of one of the above
 Score – 0
● None at all

5. Reorienting 1. The workplace either provides Minimum Standard:

Health access to (through referral) or
Services directly delivers preventive and Score – 2 ● Number of workers
promotive health services related ● 80% of workers availed who avail of
to the promotion of healthy diet the promotive and promotive and
and physical activity. preventive preventive health
health services offered by services offered by
the workplace.
the workplace.

● Name of health
service provider,
whether in-house or
● Presence of health service
provider, whether in-house
or

through a referral network, through a referral

to deliver promotive and network, to deliver
preventive health services promotive and
related to healthy diet and preventive health
physical activity. services related to
healthy diet and
physical activity.
(Health documents/
results from the
identified health
service provider of
the workplace)
 Score – 1
● Presence of one of the above

Score – 0
● None at all

Total Score

Priority Area 2. ENVIRONMENTAL HEALTH

Action Area Indicator Guide to Scoring Score Comments/Means
(0-2) of Verification

(A) (B) (C) (D) (E)

1. Developing 1. The workplace has a Minimum Standard:

Healthy Public workplace policy promoting Score - 2 ● Signed Policy
Policy environmental health in the ● The workplace has from
workplace disseminated an issuance Management
related to the promotion of and Workers
environmental health within
the workplace.
● Mode of
dissemination
(Seminar/forum/e
mail/online, etc)

● There are organized ● List of Advocate

Advocates/Volunteer Groups Groups/Voluntee
or Teams promoting r
environmental health in the groups/teams
workplace. promoting
environmental
Score -1 health
● Presence of one of the above

Score -0
● none at all

2. Creating a 1. The workplace provides the Minimum Standard:

Supportive needed facilities/equipment and
Environment other services to support the Score - 2
promotion of environmental ● 80% of workers have ● No of workers
health in the workplace. access to facilities to support accessing
the facilities/total
promotion of environmental number of
health in the workplace employees
(Records/Logbook
, Attendance
sheets/DPO/etc)

● There is an issued
● Management provides or policy (or its
allows privileged time for equivalent) that
workers participating in the allows privileged
promotion of environmental Time to workers
health.. on their
participation to
Score - 1 advocacy
● Presence of one of the above
 Score – 0 activities for the
● none at all promotion of
environmental
health.
● Number of
workers who
have
been allowed
privileges (e.g.
privileged time)
for their
participation in
promoting
environmental
health out of the

total no. of
workers.
(Company
order/DPO,
certificate of
privileged time,
etc.)

3. Developing 1. The workplace company Minimum Standard:

Personal Skills provides training and personal Score – 2 ● List/Number of
development skills related to the ● Provision of training training courses
promotion of environmental opportunities related to provided related to
health in the workplace. environmental health by Environmental
management Health

● Number of
workers who
● Minimum of 50% employees
availed of the
availed training related to
allowed or
environmental health
orientation related
to environmental
healthy/Total
Number of
Workers
Score – 1
● Presence of one of the above

Score – 0
● None at all

1. The workplace actively Minimum Standard:

supports and participates LGU-
led or Score – 2
4. community-hosted ● 50% of workers actively ● Number of
Strengthening projects/activities related to support or participate in workers who
Community environmental health. LGU-led or community actively
Action hosted projects/activities participate/support
related to environmental LGU-led or
health community-hosted
activities related to
environmental
health/Total
Number of
workers

● LGU-led, community-hosted ● List of LGU-led

activities supported by the or community
workplace (monetary and hosted activities
non-monetary support) supported by the
company
(monetary and
Score – 1 non-monetary
● Presence of one of the above

Score – 0
● None at all

5. Reorienting 1. The workplace either Minimum Standard: ● Number of

Health provides access to (through workers who
Services referral) or directly delivers Score – 2 avail
preventive and promotive health ● 80% of workers availed of promotive and
services related to the the promotive and
preventive health
promotion of environmental preventive
health. health services offered by services offered by
the workplace. the workplace.

● Name of health
service provider,
 ● Provide access to
promotive/preventive health
services such as screening,

diagnosis, counseling, health whether in-house

promotion and referral or through a
system. referral network,
to deliver
Score – 1 promotive and
● Presence of one of the above preventive health
Score – 0 services related to
● None at all environmental
health (Health
documents/ results
from the identified
health service
provider of the
workplace)

Total Score

Priority Area 3. IMMUNIZATION

Action Area Indicator Guide to Scoring Score Comments/Means
(0-2) of Verification
 (A) (B) (C) (D) (E)

1. 1. The workplace has a workplace Minimum Standard: ● Signed Policy

Developing policy promoting immunization in from
Healthy the workplace Score - 2 Management
Public ● The workplace has and Workers
Policy disseminated an issuance
related to the promotion of
immunization within the ● Mode of
workplace. dissemination
(Seminar/forum/e
mail/online, etc)

● List of Advocate
● There are organized Groups/Voluntee
Advocates/Volunteer Groups r
or Teams promoting groups/teams
immunization in the promoting
workplace. immunization

Score -1
● Presence of one of the above

Score -0
● none at all

2. Creating a 1. The workplace provides the Minimum Standard: ● There is an issued

Supportive needed facilities/equipment or policy (or its
Environment privileges to support the Score – 2 equivalent) that
promotion of immunization in the
workplace. ● 80% of workers have access
to facilities/equipment in
support to the promotion of
 immunization in the allows privileged
workplace Time to workers
on their
● Management provides or participation in
allows privileged time for advocacy
workers participating in activities for the
healthy diet and physical promotion of
activities immunization
Score -1
● Number of
● Presence of one of the above
workers who
Score – 0 have
● none at all been allowed
privileges (e.g.
privileged time)
for their
participation in
promoting
immunization out
of the total no. of
workers.
(Company
order/DPO,
certificate of
privileged time,
etc.)

3. 1. The workplace provides Minimum Standard:

Developing training and personal skills
Personal development related to the Score – 2
Skills promotion of immunization in the
workplace. ● Provision of training
opportunities related to
 immunization by ● List of training or
management. orientation
courses
related to
immunization
allowed by
Management for
● Minimum of 50% of workers
attendance of
availed the allowed training
workers
or orientation related to
immunization

Score – 1 ● Number of
● Presence of one of the above workers who
Score – 0 availed of the
● None at all allowed training or
orientation related
to
immunization/Tot
al Number of
Workers

4. 1. The workplace actively Minimum Standard: ● Number of

Strengtheni supports and participates in LGU- workers who
ng led or community-hosted Score – 2 actively
Community projects/activities related to participate/suppor
Action immunization ● 50% of workers actively t LGU-led or
support or participate in community
LGU-led or community hosted activities
hosted projects/activities related to
related to immunization. immunization/Tot
 ● LGU-led, community-hosted
activities supported by the

workplace (monetary and al Number of

non-monetary support) workers

● List of LGU-led
or community
Score – 1 hosted activities
● Presence of one of the above supported by the
company
Score – 0 (monetary and
● None at all non-monetary)

5. 1. The workplace either provides Minimum Standard:

Reorienting access to (through referral) or Score – 2 ● Number of
Health directly delivers preventive and ● 80% of workers availed workers who
Services promotive health services related the promotive and avail
to the promotion of preventive of promotive and
immunization. health services offered by preventive health
the workplace.
services offered by
the workplace.
● Name of health
service provider,
whether in-house
● Presence of health service
provider, whether in-house or through a
or through a referral referral network,
network, to deliver to deliver
promotive and promotive and
preventive health services preventive health
related to immunization. services related to
immunization.(He
alth documents/
results from the
identified health

service provider of
the workplace)

Score – 1
● Presence of one of the above

Score – 0
● None at all

Total Score
Priority Area 4. SUBSTANCE USE
Action Area Indicator Guide to Scoring Score Comments/Means
(0-2) of Verification

(A) (B) (C) (D) (E)

1. Developing 1. The workplace has a Minimum Standard: ● Signed Policy

Healthy Public workplace policy in addressing from
Policy substance use in the workplace Score - 2 Management
and Workers
● The workplace has
disseminated an issuance
● Mode of
related to addressing
substance use in the dissemination
workplace. (Seminar/forum/e
mail/online, etc)

● List of Advocate
Groups/Voluntee
r
● There are organized
groups/teams on
Advocates/Volunteer
Groups or Teams in substance use
addressing substance use in
the workplace.

Score -1
● Presence of one of the above

Score -0
 ● none at all

Minimum Standard:

2. Creating a 1. The workplace provides the ● Number of

Supportive needed facilities/equipment or workers
Environment privileges in addressing Score – 2 accessing
substance use in the workplace. facilities/equipme
● 80% of workers have access nt in addressing
to facilities/equipment in substance use out
addressing substance use in of the total number
the workplace of workers
(Records/Logbook
● Management provides or
sAttendance sheet/
allows privileged time for
DPO/ etc)
workers participating in
addressing substance use in ● There is an issued
the workplace policy (or its
Score -1 equivalent) that
● Presence of one of the above allows privileged
 Score – 0 Time to workers
● none at all on their
participation to
advocacy
activities for the
substance use.

● Number of
workers who
have
been allowed
privileges (e.g.
privileged time)
for their
participation in

addressing
substance use out
of the total no. of
workers.
(Company
order/DPO,
certificate of
privileged time,
etc.)

3. Developing 1. The workplace provides Minimum Standard:

Personal Skills training and personal skills Score – 2 ● List of training or
development related addressing orientation
substance use in the workplace. ● Provision of training courses
opportunities related to related to healthy
addressing substance use by diet and physical
management.
activities allowed
by Management
for attendance of
● Minimum of 50% of workers
workers availed the allowed
training ● Number of
or orientation related to workers who
healthy diet and physical availed of the
activity allowed training or
orientation related
to healthy diet and
physical
activity/Total
Score – 1 Number of
● Presence of one of the above Workers

Score – 0

● None at all

4. 1. The workplace actively Minimum Standard: ● Number of

Strengthening supports and participates in LGU workers who
Community led or community-hosted Score – 2 actively
Action projects/activities related to ● 50% of workers actively participate/suppor
addressing substance use. support or participate in t LGU-led or
LGU-led or community community
hosted projects/activities hosted activities
 related to addressing related to
substance use. addressing
substance use
Score – 1 /Total Number of
● Presence of one of the above workers
Score – 0
● None at all ● List of LGU-led
or community
hosted activities
supported by the
company
(monetary and
non-monetary)

5. Reorienting 1. The workplace either Minimum Standard: ● Number of

Health provides access to (through workers who
Services referral) or directly delivers Score – 2 avail
preventive and promotive health ● 80% of workers availed of promotive and
services related to addressing the promotive and preventive health
substance use. preventive services offered by
health services offered by the workplace.
the workplace.
● Presence of health service ● Name of health
provider, whether in-house service provider,
or through a referral
network, to deliver
promotive and
preventive health services
 related to addressing whether in-house
substance use. or through a
referral network,
Score – 1 to deliver
● Presence of one of the above promotive and
Score – 0 preventive health
● None at all services related to
addressing
substance use.
(Health
documents/ results
from the identified
health service
provider of the
workplace)

Total Score

Priority Area 5. MENTAL HEALTH

Action Area Indicator Guide to Scoring Score Comments/Means
(0-2) of Verification

(A) (B) (C) (D) (E)

1. Developing 1. The workplace has a Minimum Standard: ● Signed Policy

Healthy Public workplace policy promoting from
Policy mental health in the workplace. Score - 2 Management
● The workplace has and Workers
disseminated an issuance
related to the promotion of ● Mode of
 mental health within the
workplace. dissemination
(Seminar/forum/e
● There are organized mail/online, etc)
Advocates/Volunteer
Groups or Teams ● List of workers
promoting mental health in who are
the workplace. Advocates
or members of
Score -1 Groups/Volunteer
● Presence of one of the above groups/teams
promoting mental
Score -0
health.
● none at all

2. Creating a 1. The workplace provides the Minimum Standard: ● Number of

Supportive needed facilities/equipment or workers
Environment privileges to support the Score – 2 accessing
promotion of mental health in ● 80% of workers have access facilities/equipme
the workplace to facilities/equipment in nt to promote
support to the promotion of mental health out
mental health in the
workplace
 ● Management provides or of the total number
allows privileged time for of workers
workers participating in the (Records/Logbook
promotion of mental health sAttendance sheet/
DPO/ etc)

● There is an issued
policy (or its
equivalent) that
allows privileged
Time to workers
on their
● Management provides or participation to
allows privileged time for advocacy
employees participating in activities for the
activities that support the promotion of
promotion of mental health mental health.
in the workplace
● Number of
Score -1 workers who
● Presence of one of the above have
been allowed
Score – 0
privileges (e.g.
● none at all
privileged time)
for their
participation in
promoting mental
health out of the
total no. of
workers.
(Company
order/DPO,
certificate of
 privileged time,
etc.)

3. Developing 1. The workplace provides Minimum Standard: ● List of training or

Personal Skills training and personal skills orientation
development related to the Score – 2 courses
promotion of mental health in ● Provision of training related to
the workplace. opportunities related to the promotion of
promotion of mental health mental health
by management. allowed by
Management for
● Minimum of 50% of workers attendance of
availed the allowed training workers
or orientation related to the
promotion of mental health ● Number of
workers who
Score – 1
● Presence of one of the above availed of the
allowed training or
Score – 0 orientation related
● None at all to the promotion
of mental
health/Total
Number of
workers

4. 1. The workplace actively Minimum Standard: ● Number of

Strengthening supports and participates in LGU workers who
Community led or community-hosted Score – 2 actively
Action projects/activities related to the ● 50% of workers actively participate/suppor
promotion of mental health. support or participate in t LGU-led or
LGU-led or community
hosted projects/activities

related to the promotion of community

mental health. hosted activities
related to the
promotion of
● LGU-led, community-hosted mental
activities supported by the health/Total
workplace (monetary and Number of
non-monetary support) workers

Score – 1 ● List of LGU-led

● Presence of one of the above or community
hosted activities
Score – 0
supported by the
● None at all
company
(monetary and
non-monetary)

5. Reorienting 1. The workplace either Minimum Standard:

 Health provides access to (through Score – 2 ● Number of
Services referral) or directly delivers ● 80% of workers availed workers who
preventive and promotive health the promotive and avail
services related to the preventive of promotive and
promotion of mental health. health services offered by preventive health
the workplace.
services offered by
the workplace
● Presence of health service
provider, whether in-house ● Name of health
or through a referral service provider,
network, to deliver whether in-house
promotive and
or through a
preventive health services
related to mental health. referral network,
to deliver
promotive and
preventive health

● services related to
healthy diet and
Score – 1 physical activity.
● Presence of one of the above (Health
documents/ results
Score – 0
from the identified
● None at all
health service
provider of the
workplace

Total Score

Priority Area 6. SEXUAL and REPRODUCTIVE HEALTH

 Action Area Indicator Guide to Scoring Score Comments/Means
(0-2) of Verification

(A) (B) (C) (D) (E)

1. Developing 1. The workplace has a Minimum Standard: ● Signed Policy

Healthy Public workplace policy promoting from
Policy sexual and reproductive health Score - 2 Management
in the workplace ● The workplace has and Workers
disseminated an issuance ● Mode of
related to the promotion of
dissemination
sexual and reproductive
health within the workplace. (Seminar/forum/e
mail/online, etc)
● There are organized
Advocates/Volunteer ● List of workers
Groups or Teams who are
promoting sexual and Advocates
reproductive health in the or members of
workplace. Groups/Volunteer
Score -1 groups/teams
● Presence of one of the above promoting sexual
and reproductive
Score -0 health.
● none at all

2. Creating a 1. The workplace provides the Minimum Standard: ● Number of

Supportive needed facilities/equipment or workers
Environment privileges to support the Score – 2 accessing
promotion of sexual and facilities/equipme
reproductive health in the ● 80% of workers have access
workplace. to facilities/equipment in
support of the promotion of
 sexual and reproductive nt to promote
health in the workplace healthy diet and
physical activities
● Management provides or out of the total
allows privileged time for number of workers
workers participating in the (Records/Logbook
promotion of sexual and sAttendance sheet/
reproductive health DPO/ etc)
Score -1
● Presence of one of the above
Score – 0
● none at all

● There is an issued
policy (or its
equivalent) that
allows privileged
Time to workers
on their
participation to
advocacy
activities for the
promotion of
sexual and
reproductive
health

● Number of
workers who
have
been allowed
privileges (e.g.
privileged time)
for their
participation in
 promoting sexual
and reproductive
health out of the
total no. of
workers.
(Company
order/DPO,
certificate of
privileged time,
etc.)

3. Developing 1. The workplace provides Minimum Standard: ● List of training or

Personal Skills training and personal skills orientation
development related to the Score – 2 courses
promotion of sexual and related to sexual
reproductive health in the ● Provision of training and reproductive
workplace. opportunities related to health allowed by
sexual and reproductive Management for
health by management. attendance of
workers

● Number of
● Minimum of 50% of
workers who
workers availed the allowed
availed of the
training
allowed training or
or orientation related to
orientation related
sexual and reproductive
to sexual and
health
reproductive
Score – 1 health/Total
● Presence of one of the above Number of
 Score – 0 Workers
● None at all

4. Strengthening 1. The workplace actively Minimum Standard: ● Number of

Community supports and participates in workers who
Action LGU-led or community-hosted Score – 2 actively
projects/activities related to ● 50% of workers actively participate/support
sexual and reproductive health. support or participate in LGU-led or
LGU-led or community community-hosted
hosted projects/activities activities related to
related to sexual and sexual and
reproductive health. reproductive
health/Total
● LGU-led, community-hosted Number of
activities supported by the workers
workplace (monetary and
non-monetary support) ● List of LGU-led
or community-
Score – 1 hosted
● Presence of one of the above activities
supported by the
Score – 0 company
● None at all (monetary and
non-monetary)
5. Reorienting 1. The workplace either Minimum Standard: ● Number of
Health Services provides access to (through workers who
referral) or directly delivers Score – 2 avail
preventive and promotive ● 80% of workers availed of promotive and
health services related to the the promotive and preventive health
promotion of sexual and preventive
reproductive health. services offered by
health services offered by
the workplace. the workplace.
● Presence of health service
provider, whether in-house
or through a referral
network, to

deliver promotive and ● Name of health

preventive health services service provider,
related to sexual and whether in-house
reproductive health. or through a
referral network,
Score – 1
to deliver
● Presence of one of the above
promotive and
Score – 0 preventive health
● None at all services related to
sexual and
reproductive
health. (Health
documents/ results
from the identified
health service
provider of the
workplace
 Total Score

Priority Area 7. VIOLENCE and INJURY PREVENTION

Action Area Indicator Guide to Scoring Score Comments/Means
(0-2) of Verification

(A) (B) (C) (D) (E)

1. Developing 1. The workplace has a Minimum Standard: ● Signed Policy

Healthy Public workplace policy on from
Policy addressing violence and injury Score - 2 Management
prevention in the workplace and Workers
● The workplace has ● Mode of
disseminated an issuance
dissemination
related to violence and
injury prevention within the (Seminar/forum/e
workplace. mail/online, etc)

● List of workers
who are
● There are organized Advocates
Advocates/Volunteer or members of
Groups or Teams on
Groups/Volunteer
violence and injury
prevention in the groups/teams on
workplace. violence and
injury prevention

Score -1
● Presence of one of the above

Score -0
● none at all
2. Creating a 1. The workplace provides the Minimum Standard:
Supportive needed facilities/equipment or
Environment privileges to support the Score – 2

prevention of violence and ● 80% of workers have access ● Number of

injury in the workplace. to facilities/equipment in workers
support to the violence and accessing
injury prevention in the facilities/equipme
workplace nt to violence and
injury prevention
out of the total
number of workers
● Management provides or (Records/Logbook
allows privileged time for sAttendance sheet/
workers participating in DPO/ etc)
violence and injury
prevention

● There is an issued
Score -1 policy (or its
● Presence of one of the above
Score – 0 equivalent) that
● none at all allows privileged
Time to workers
on their
participation to
advocacy
activities on
violence and
injury prevention

● Number of
workers who
have
been allowed
privileges (e.g.
privileged time)
for their
 participation in
violence and
injury prevention
out of the total no.
of workers.
(Company
order/DPO,
certificate of
privileged time,
etc.)
3. Developing 1. The workplace provides Minimum Standard: ● List of training or
Personal Skills training and personal skills orientation
development related to Score – 2 courses
violence and injury prevention related to violence
in the workplace. ● Provision of training
opportunities related to and injury
violence and injury prevention
prevention by management. allowed by
Management for
attendance of
workers
● Minimum of 50% of
workers availed the allowed ● Number of
training workers who
or orientation related to availed of the
violence and injury
allowed training or
prevention
orientation related
to healthy diet and
Score – 1 physical
● Presence of one of the above activity/Total

Score – 0
● None at all

Number of
Workers

4. Strengthening 1. The workplace actively Minimum Standard: ● Number of

Community supports and participates in Score – 2 workers who
Action LGU- led or community-hosted ● 50% of workers actively actively
projects/activities related to support or participate in participate/support
violence and injury prevention. LGU-led or community LGU-led or
hosted projects/activities community-hosted
related to violence and injury activities related to
prevention. violence and
injury
● LGU-led, community-hosted prevention/Total
activities supported by the Number of
workplace (monetary and workers
non-monetary support)
● List of LGU-led
Score – 1 or community-
● Presence of one of the above hosted
activities
Score – 0 supported by the
● None at all company
(monetary and
non-monetary)

5. Reorienting 1. The workplace either Minimum Standard: ● Number of

Health Services provides access to (through workers who
referral) or directly delivers Score – 2 avail
preventive and promotive ● 80% of workers availed of promotive and
health services related to the the promotive and preventive health
violence and injury preventive services offered by
prevention. health services offered by the workplace
the workplace. ● Name of health
● Presence of health service service provider,
provider, whether in-house whether in-house
or through a referral
network, to deliver
promotive and
 preventive health services or through a
related to violence and injury referral network,
prevention. to deliver
promotive and
Score – 1 preventive health
● Presence of one of the above services related to
violence and
Score – 0 injury prevention.
● None at all ((Health
documents/ results
from the identified
health service
provider of the
workplace)

Total Score

Part 3: Interpretation of Responses and Recommendations

Instructions: Please fill up the matrix below by referring to the scores recorded in the Self Assessment Form. Compute the
Total Points (G) by adding the scores per Action Area (B/C/D/E/F)

Scoring Matrix
Priority Area Action Areas for Implementation Total Recommendatio
Points ns (Prefer to
Score Per Action Area (Maximu Scoring
m 10 Recommendatio
Developi Creating Developi Strengtheni Reorienti points) n Matrix)
ng Supportive ng ng ng Health
Healthy Environme Personal Community Services
 Policy nt Skills Action

(A) (B) (C) (D) (E) (F) (G) (H)

Diet/Physical
Activity

Environment
al Health

Immunization

Substance Abuse

Mental Health

Sexual and
Reproductive
Health

Violence and
Injury
Prevention

Score Recommendations:
Score Recommendation/s Remarks

10 points ● Plan for the sustainability of ● Develop a sustainability plan for continual improvement.
current actions/activities

5 to 9 points ● Plan for immediate ● Prioritize Priority Areas with scores of 5-9 points
improvement ● Develop strategic activities on the Action Areas to complete the
 minimum standard.

0 to 4 points ● Decide if the Priority Area ● Identify and decide if the concerned Priority Area is relevant in
is Relevant and there is the workplace.
high interests among the ● Factors to consider in the decision process may be the following:
workers o There is demand or interest from the workers to
implement health Priority Area/s concern
o Strategies and activities are doable and can be
implemented easily.
o Strategies and activities will provide positive health and
safety impact to the workers.