While the majority of employers in the US consist of small businesses, they have received less attention from occupational safety and health and Total Worker Health® practitioners. Based on the Institute of Medicine’s Employee Total Health Management model, a foundational model for TWH, statewide surveys and focus groups of Iowa employers (Merchant et al., 2013; Merchant et al., 2014) identified the health and safety practices and needs of workplaces and examined their burden on employers and employees and the corresponding impact on rising healthcare costs, productivity, and, most importantly, worker health and well-being. In 2016-2017, we conducted a modified version of the survey with small employers (employees <250) not only in Iowa but throughout Federal Region VII (Iowa, Kansas, Nebraska and Missouri). Federal Region VII disproportionately suffer from higher burdens of occupational injury and illness, as well as high rates of unhealthy behaviors compared to other regions of the country. Results suggested the vast majority of small employers have adopted at least one safety and health program or policy, reported good employee participation in program development, and are evaluating participation and some outcomes. However, there was a reported lack of support for both safety and health programs from management, and organizations were either in pre-contemplation or maintenance stages of change regarding the adoption of programs. In other words, few employers are contemplating or actively preparing to make additional changes to their safety and health programs. In comparing the 2012 data with the current data collection, Iowa did see a significant rise in the adoption of programs addressing safety, wellness, and behavioral health. Despite the adoption of programs that have some characteristics of TWH, survey results showed lack of awareness in the term “Total Worker Health.” Results from this study are forthcoming in a new book, Total Worker Health, edited by John Howard, Casey Chosewood, Anita Schill, Heidi Hudson, and Sarah Tamers of NIOSH.