Wellness Program Guide - TriHealth...• Health/Wellness Activities • Biometrics B. The City will...

Confidentiality Statement

All Personal Health Information (PHI) shall be held strictly confidential by the TriHealth Wellness

Coordinator, a non-city employee.

The City of Montgomery will not have access to any individual participant’s Personal Health

Information, but will review data in aggregate form only. The City of Montgomery recognizes the

importance of assuring participants that their PHI will remain confidential and that no information

gathered from the program will ever be used against a participant.

Wellness Staff Erin Pauley | Wellness Coordinator | 513 977 0026 Email: [email protected] EFax: 513 852 3881 11129 Kenwood Rd, Cincinnati, OH 45242

Erica Keeney | Wellness Specialist | 513 977 0045 Email: [email protected] Fax: 513 891 7286 11129 Kenwood Rd, Cincinnati, OH 45242

© 2010 Bethesda Healthcare, Inc. All rights reserved. Copying or reproducing this document is strictly prohibited

REGULAR

EXERCISE

Community

Run/Walk

EDUCATIONAL

EVENTS

Program Disclaimers Your doctor should play a primary role in guiding your overall health and physical well-being. The U.S. Surgeon

General's report, Physical Activity and Health, recommends that you consult with your personal care physician

before beginning any physical activity/exercise program (including recreational activities).

Why Should I Participate in the Wellness Program? The Wellness Program is an opportunity for employees to be rewarded for making healthy lifestyle choices.

Employees can earn points, which accumulate thr oughout the year, for participating in related wellness events

such as:

• Health Screenings

• Preventive Care Screenings

• Regular Physician Visits

• Health Fairs

• Personal Training Sessions

• Regular Exercise

• Athletic League Participation

• And Much More!

Full Time Employees in the Wellness Program can earn up to $500

per year in the GOLD level!

Permanent Part Time Employees in the Wellness Program can

earn up to $250 per year in the GOLD level!


How Do I Participate In the Wellness Program?

Complete your Health Risk Assessment (HRA) and Biometric Screening with TriHealth each January. This is

the only required activity to be in the Wellness Program. If you have missed the January screening dates, please

contact your Wellness Coordinator to set up a screening and HRA.

View the Wellness Calendar and Scorecard which are attached to the program guide. This calendar lists all the

events that you can attend to start earning points. The scorecard includes all opportunities to earn points; this

includes preventive exams, exercise tracking, Vitality Quizzes, athletic league participation, community

runs/walks and others. Also be sure to view the Points Map which will help you map out your route to earn the

Gold Level Award. Below are examples of ways to obtain points:

Attend an event: be sure to sign in at the event to have your points added to your scorecard.

Preventive Exams: Take the Health Confirmation Form (form attached) to your doctor’s visit and fax

the completed form to 513-852-3889.

Exercise Tracking: complete the Exercise Tracking Log and fax it to 513-852-3889 each month.

Athletic League or Community Run/Walk: Submit a copy of the registration form or receipt by

faxing it to 513-852-3889.

The deadline to submit points is December 31st. During the month of January all points will be calculated and

updated.

*Check the Wellness website to view our monthly updates and upcoming programming:

Montgomery Wellness Website

Full website address:

https://wellsuite.com/trihealthcorphealth/trihealthphs/default.aspx?grid=6f96bbd16211

Procedure:

I. Wellness Incentive Eligibility

A. A voluntary wellness incentive program with a goal to encourage healthy lifestyles will be offered to all employees annually. Program events may be open to employee family members.

• The duration of the program will be January through December of each year.

• The City wellness program is open to all full and permanent part-time employees.

a. Employees may join the program any time throughout the calendar year.

b. To be eligible for any monetary award, the employee must be employed as of December 31 of the program year.

• Employees must earn a minimum of 300 points to convert points to dollars. Points earned by the employee will be converted to a monetary reward at the conclusion of the annual program period. A maximum of $500 for full time employees or $250 for part-time employees can be earned, regardless of the number of points accumulated by the participating employee. Points will be converted to dollar amounts for full time employees as follows:

HRA and 300 – 345 points $300


HRA and 400 points or more $500

Points will be converted to dollar amounts for part-time employees as follows:



HRA and 400 points or more $250

• To participate in the program, an employee must complete a registration form and a Health Risk Assessment annually.

• Employees are under no obligation to participate in the Wellness Program. Participation is strictly voluntary and is not part of an employee’s duties or work responsibility to the City. All participation is to be done on personal time, off the job. If injured during an employee’s participation in a wellness activity, the City will not recognize this injury as an on the job injury, and the City will not accept Worker’s Compensation responsibility for such injury. Additionally, such injuries are not recognizable as an occupational leave injury. Employees participate in the program voluntarily, and employees participate in any program activities at their own risk. All participating employees must sign a ‘Waiver of Workers Compensation Benefits and Full Release of Liability for Recreational or Fitness Activities’ (reference Policy VI-8: Waiver of Workers’ Compensation Benefits and Full Release of Liability for Recreational or Fitness Activities) for each event as well as at the beginning of each calendar year for participation in the program and use of City workout facilities. Participating Employees will also be required to sign a Wellness Program Release Form.

II. Management of Wellness Incentive Program

A. The incentive program shall consist of five categories:

• Physical Participation

• Educational

• Preventive Care

• Health/Wellness Activities

• Biometrics

B. The City will contract the management of the program to an outside source to be determined annually.

• Records of employee participation and employee personal data will be stored at the contract agency site. The only employee information to be kept on site at City Hall will be the total points earned and money paid to the employee.

• The Wellness Management Team, with approval of the Wellness Committee liaisons, will offer programs and classes to supplement City Recreation fitness programs.

III. Point Structure

A. Points to Incentive Conversion and Minimum

• Fulltime employees can earn up to a maximum of $500 through points accumulated in the five categories.

• Part-time employees can earn up to a maximum of $250 through points accumulated in the five categories.

a. Employee must earn a minimum of 300 points to convert points to dollars.

B. Physical Participation points can be earned General Fitness Assessment (GFA) results, or through workout sessions.

• Points earned through General Fitness Assessment results will be based inflexibility, upper body strength, core strength, and cardiovascular fitness. Measurement will be converted to gender and age based standards. (ACSM standards and percentages will be used). Points in each of the five areas of physical condition can be earned through the assessment described below.

a. If beginning and ending measure is at the Average category or better:

Category Points Earned

Cardiovascular 20pts

Core Strength 20pts

Upper Body Strength 20pts

Flexibility 20pts

• Points may be earned through verified workouts, miles walked/ run/ or biked. A form will be provided to the employee to record the workouts/classes attended. The instructor or fitness center staff must sign the form as verification of the workout session. Workouts cannot be verified by any city employee.

a. The Wellness Management Team will be responsible for collection of workout sign-off forms, and the contracted administrator will be responsible for verification of the data on the forms and assignment and tracking of points.

b. Verified Workouts: Monitored workout sessions or classes must be recorded on a provided form, dated and initialed by class instructor. Walk/run/bike sessions tracked by a pedometer/cyclometer must be logged, dated and signed by the employee and a Wellness Management Team member or Contract Administrator when the pedometer is cleared. A verified workout is classified below:

• 30+ minutes workout session or class

• 2 miles walked or run*

• 6 miles biked*

* A pedometer or cyclometer will be necessary to verify miles biked, walked or run and is secured at the employee’s expense. The pedometer is to be used during 30-minute or more walk/ run workout sessions, not for walking during your daily activities.

• Points earned can be from any one or combination of the above

• Verification of points earned will be collected quarterly from the Wellness Management Team and tallied by the contracted administrator. Additional tally forms and log sheets can be obtained from a Wellness Committee member or contract administrator and will be distributed to all participants quarterly or as needed.

C. Education points can be earned through attendance at Lunch & Learn lectures, through participation in the City sponsored Health Fairs, and educational quizzes.

• Lunch & Learn lectures will be coordinated and provided bimonthly by the Wellness Management Team. Each topic will be presented once in each building on a specific topic, to provide ample opportunity for employee and family member participation. Family participation is encouraged in conjunction with employee wellness for the benefits to be most effective in a long-term change.

• Five (5) points will be earned for each different lecture topic attended by the employee.

• City sponsored mini Health Fairs will be scheduled biannually, offering a variety of education and health care services to be coordinated by the Wellness Management Team. Employee participation in each fair will result in a 10-point award.

• Employees and their families are encouraged to participate in the Lunch & Learn lectures and the City Health Fairs. However, only the employee participation will be credited toward point accumulation.

• Vitality wellness magazine is distributed to all employees on a monthly basis. There will be monthly quizzes generated from each magazine with 3-8 questions pulled from that month’s edition. Employees who answer the questions correctly and submit their responses within a week’s time to the designated person from the wellness committee will be awarded 5 points.

• The Wellness Committee will offer additional opportunities for educational points throughout the year to encourage participants to continually learn more about personal wellness and to educate others to ultimately have a more health conscience and well work team. Incentives other than points may be used with these opportunities.

D. Preventive Care points can be earned through any of the below listed menu of items:

• Dental – Preventive/Cleaning Only (max 2 per year) 15 pts. each

• Flu Shot (one per year) 10 pts.

• Comprehensive Physical Exam by a medical doctor 30 pts.

Exam must include the following Tests: Examination of eyes, ears, throat, neck and

spinal, heart rate and blood pressure, lung – breathing, abdomen palpitation, knee and

ankle reflex and range of motion at a minimum. All tests must be performed by an

authorized health care professional and verified with a signature on the Montgomery

wellness physician form. These tests are in accordance with standards for a

comprehensive physical exam.

• Comprehensive Eye Exam 20 pts.

Exam must include the following Tests: visual acuity test, pupillary exam, dilated fundus

exam, intraocular pressure test and limited muscle exam. All tests must be performed by

an authorized eye care professional and verified with a signature on the Montgomery

wellness eye form. Tests are in accordance with standards for a comprehensive eye exam.

• Wellness Screenings (PSA, mammogram, etc.) 25 pts.

(Maximum of 25 points per year for one or more tests performed excluding the

cholesterol screening done as part of the HRA or comprehensive physical)

• Dermatology Full Body Exam (one per year) 10 pts.

• Completing Fitness Assessment (GFA) 30 pts.

Includes 5 areas of fitness: flexibility, strength, aerobic, body fat, and endurance

1. Points for all of the above are applicable only one time per year (except for dental prevention care, as noted).

2. Points will not be awarded in applicable areas listed above without verification from the dental or health care provider.

3. Points earned can be from any one or combination of the above

E. Biometrics points can be earned through any of the below listed menu of items:

• Biometric Test (one per year) 30 pts.

• Body Composition (average or better) 20 pts.

• Blood Pressure (<120/<80) 20 pts.

• Fasting Blood Glucose (65-99mg/dl) 20 pts.

• Total Cholesterol (<200mg/dl) 20 pts.

• LDL Cholesterol (<100mg/dl) 20 pts.

• HDL Cholesterol (>60mg/dl) 20 pts.

• Triglycerides (<150mg/dl) 20 pts.

• Ab Circumference (<40” men / <35” women) 20 pts.

F. Health/Wellness Activities points can be earned through any of the below listed menu of items:

• Incentive Programs, which are intended to be team building events, will be organized three times a year. Point potential will be 15 points per activity. These team building events will require that the participant complete the event with verifiable results before points are awarded.

• Organized single-date team activities will be available twice a year. 15 points will be awarded for participation in these single-date activities. Some examples of single-date team activities include sand volleyball, bowling, a kickball game, etc. These activities will be organized as part of the wellness program and qualify as team activities being that they are geared to bring co-workers together to work as a team in a fun and physical activity.

V. Appeal Process

• A subcommittee of the Wellness Committee will hear any appeals or disputes over points earned, pre-approval for lifestyle education programs, or other issues that may arise concerning the Wellness Incentive Program. The subcommittee will make a recommendation to the City Manager on any appeal or dispute. The City Manager shall have final authority on the resolution of any appeal or dispute.


City of Montgomery Points Program 11/8/11 updated Wellness Measures Frequency/Range Points My Points Health Risk Assessment (HRA) 1 per year Required No Points Awarded

Prevention

Physical Exam Annually or on doctor’s recommendation 30

Pap Smear Recommended for women after age 18 25

PSA Recommended for men after age 50 25

Colonoscopy Recommended at age 50 and older 25

Mammogram Recommended for women age 40 and older 25

Eye Exam 1 per year 20

Dermatology Full Body Exam 1 per year 10

Dental Cleaning (2) 2 per year 15 each

Flu Shot 1 per year 10

*Some exams may not be recommended annually. Talk to your doctor about the frequency and age you should be tested.

Biometrics

Biometric Test 1 per year 30

Body Composition Average or better 20

Blood Pressure <120/<80 20

Fasting Blood Glucose 65-99mg/dl 20

Total Cholesterol <200mg/dl 20

LDL Cholesterol <100mg/dl 20

HDL Cholesterol >60mg/dl 20

Triglycerides <150mg/dl 20

Ab Circumference <40 inches Men/ <35 inches Women 20

*Values are from the American Medical Association **You may resubmit numbers at any time once per year provided you submit the entire panel of tests

Health/Wellness Activities

Incentive Program Participation Offered by TriHealth/ 3 per year 15 each

Team Outing (2) Organized event with 5 or more employees 15 each

Educational Activities

Health Fair (2) 2 per year 10 each

Nutrition Consult by TriHealth 1 per year 5

Lunch and Learn (6) 6 per year 5 each

Vitality Quizzes (12) once per month/12 per year 5 each

Physical Activities

General Fitness Assessment 1 per year 30

Cardiovascular Fitness Score Average or better - 1 per year 20

Core Strength Score Average or better - 1 per year 20

Upper Body Strength Score Average or better - 1 per year 20

Flexibility Score Average or better - 1 per year 20

Exercise Tracking Monthly Workout Log - 12 per year 10 each

Walking Program 8 week participation minimum – 1 per year 15

Personal Trainer/Fitness Consultation 1 per year 5

Athletic League Participation 1 per year 5

Community Walk/Run up to 4 per year with verification 5 each

MY TOTAL POINTS:

Full Time Employees

GOLD $500 Dollars HRA and 400 points or more

SILVER $400 Dollars HRA and 395- 350 points

BRONZE $300 Dollars HRA and 300-345 points

Part Time Employees

GOLD $250 Dollars HRA and 400 points or more

SILVER $200 Dollars HRA and 395- 350 points

BRONZE $150 Dollars HRA and 300-345 points

% Body Fat Table

AGE 20-29 30-39 MALE Low 7.1-11.7 11.3-15.8

Borderline Low 11.8-15.8 15.9-18.9

Average 15.9-19.4 19-22.2

Borderline High 19.5-25.8 22.3-27.2

High 25.9 27.3

FEMALE Low 14.5-18.9 15.5-19.9

Borderline Low 19-22 20-23

Average 22.1-25.3 23.1-26.9

Borderline High 25.4-32 27-32.7

High 32.1 32.8

City of Montgomery Points Program 2012 Outline

If a participant has an existing medical condition that makes it unreasonably difficult for the participant to achieve the program incentives or if the participant’s physician deems it is medically inadvisable for a participant to achieve the standards for the incentive under this program, please call the Wellness Coordinator at (513) 977–0020. The Wellness Coordinator will work with the participant to develop another fair way for the participant to qualify for the incentive.

Wellness Measures Descriptions Health Risk Assessment (HRA)

To be considered a 'Wellness Participant' and to receive an incentive you must take the Health Risk Assessment. You will not receive credit for any points unless you have taken the HRA. You will not receive credit for points completed before taking the HRA.

Prevention Physical Exam To receive points for a physical exam you must visit your doctor based on their

recommendation to complete the age appropriate check-ups. You must submit the proper 'Health Confirmation Form' with a signature from your doctor, a doctor's note, or printed explanation of benefits (EOB) from your insurance provider.

Pap Smear (Women Only) To receive points for a pap smear you must visit your doctor based on their recommendation to complete the age appropriate exam. You must submit the proper 'Health Confirmation Form' with a signature from your doctor, a doctor's note, or printed explanation of benefits (EOB) from your insurance provider.

PSA (Men Only) To receive points for a PSA you must complete the age appropriate screening with your doctor. You must submit the proper 'Health Confirmation Form' with a signature from your doctor, a doctor's note, or printed explanation of benefits (EOB) from your insurance provider. PSA's can also be offered through Public Health initiatives. If you receive a PSA screening with a Public Health initiative you still are required to complete the proper verification forms.

Colonoscopy To receive points for a colonoscopy you must visit your doctor based on their recommendation to complete the age appropriate exam. You must submit the proper 'Health Confirmation Form' with a signature from your doctor, a doctor's note, or printed explanation of benefits (EOB) from your insurance provider.

Mammogram (Women Only) To receive points for a mammogram you must visit your doctor based on their recommendation to complete the age appropriate exam. You must submit the proper 'Health Confirmation Form' with a signature from your doctor, a doctor's note, or printed explanation of benefits (EOB) from your insurance provider.

Eye Exam

To receive points for an eye exam you must visit your doctor based on their recommendation to complete the age appropriate exam. You must submit the proper 'Health Confirmation Form' with a signature from your doctor, a doctor's note, or printed explanation of benefits (EOB) from your insurance provider. You will not receive credit for eye exams done at the DMV.

Dermatology Full Body Exam

To receive points for a dermatology full body exam you must visit a dermatologist to complete the exam. You must submit the proper 'Health Confirmation Form' with a signature from your doctor, a doctor's note, or printed explanation of benefits (EOB) from your insurance provider.

Dental Cleaning To receive points for a dental cleaning you must visit a dermatologist to complete the exam. You must submit the proper 'Health Confirmation Form' with a signature from your doctor, a doctor's note, or printed explanation of benefits (EOB) from your insurance provider. You are able to receive points for two dental cleanings per year.

Flu Shot To receive points for a flu shot you must submit the proper 'Health Confirmation Form' with a signature from your doctor, a doctor's note, or printed explanation of benefits (EOB) from your insurance provider. Flu shots can also be offered through Public Health initiatives. If you receive a flu shot with a Public Health initiative you still are required to complete the proper verification forms.

*Some exams may not be recommended annually. Talk to your doctor about the frequency and age you should be tested.

Biometrics Biometric Test To receive credit for a biometric test you must complete a cholesterol, glucose,

blood pressure, and BMI test outside of the Health Risk Assessment. Proper wellness verification forms must be submitted.

Body Composition To receive credit for your body composition you need to take the Health Risk Assessment or have a certified health professional (doctor, nurse, personal trainer, fitness specialist) take your body composition. If you have your body composition calculated at the Health Risk Assessment and fall within the allotted range you will automatically be awarded points. If you have a health professional calculate your body composition you must submit the proper verification form with record of your BMI to the TriHealth Wellness Coordinator. If your body composition does not fall within the allotted range after taking the HRA; you have the opportunity to submit an updated body composition after the mid-point of the calendar year.

Blood Pressure To receive credit for your blood pressure you need to take the Health Risk Assessment or have a certified health professional (doctor, nurse, wellness specialist) take your blood pressure. If you have your blood pressure taken at the Health Risk Assessment and fall within the allotted range you will automatically be awarded points. If you have a health professional take your blood pressure you must submit the proper verification form with record of your blood pressure to the TriHealth Wellness Coordinator. If your blood pressure does not fall within the allotted range after taking the HRA; you have the opportunity to submit an updated blood pressure after the mid-point of the calendar year.

Fasting Blood Glucose To receive credit for your fasting blood sugar you need to take the Health Risk Assessment or have a certified health professional (doctor, nurse, wellness specialist) check your glucose reading. If you have your glucose checked at the Health Risk Assessment and fall within the allotted range you will automatically be awarded points. If you have a health professional check your glucose you must submit the proper verification form with record of your blood glucose to the TriHealth Wellness Coordinator. If your glucose reading does not fall within the allotted range after taking the HRA; you have the opportunity to submit an updated glucose reading after the mid-point of the calendar year.

Total Cholesterol To receive credit for your total cholesterol you need to take the Health Risk Assessment or have a certified health professional (doctor, nurse, wellness specialist) check your cholesterol. If you have your cholesterol checked at the Health Risk Assessment and fall within the allotted range you will automatically be awarded points. If you have a health professional check your cholesterol you must submit the proper verification form with record of your total cholesterol to the TriHealth Wellness Coordinator. If your total cholesterol reading does not fall within the allotted range after taking the HRA; you have the opportunity to submit an updated total cholesterol reading after the mid-point of the calendar year.

LDL Cholesterol To receive credit for your LDL cholesterol you need to take the Health Risk Assessment or have a certified health professional (doctor, nurse, wellness specialist) check your LDL cholesterol. If you have your LDL cholesterol checked at the Health Risk Assessment and fall within the allotted range you will automatically be awarded points. If you have a health professional check your LDL cholesterol you must submit the proper verification form with record of your LDL cholesterol to the TriHealth Wellness Coordinator. If your LDL cholesterol reading does not fall within the allotted range after taking the HRA; you have the opportunity to submit an updated LDL cholesterol reading after the mid-point of the calendar year.

HDL Cholesterol To receive credit for your HDL cholesterol you need to take the Health Risk Assessment or have a certified health professional (doctor, nurse, wellness specialist) check your HDL cholesterol. If you have your HDL cholesterol checked at the Health Risk Assessment and fall within the allotted range you will automatically be awarded points. If you have a health professional check your HDL cholesterol you must submit the proper verification form with record of your HDL cholesterol to the TriHealth Wellness Coordinator. If your HDL cholesterol reading does not fall within the allotted range after taking the HRA; you have the opportunity to submit an updated HDL cholesterol reading after the mid-point of the calendar year.

Triglycerides To receive credit for your triglyceride levels you need to take the Health Risk Assessment or have a certified health professional (doctor, nurse, wellness specialist) check your triglycerides. If you have your triglycerides checked at the Health Risk Assessment and fall within the allotted range you will automatically be awarded points. If you have a health professional check your triglycerides you must submit the proper verification form with record of your triglycerides to the TriHealth Wellness Coordinator. If your triglyceride reading does not fall within the allotted range after taking the HRA; you have the opportunity to submit an updated triglyceride level after the mid-point of the calendar year.

Ab Circumference To receive credit for your ab circumference you need to take the Health Risk Assessment or have a certified health professional (doctor, nurse, personal trainer, fitness specialist) take your ab circumference. If you have your ab circumference measured at the Health Risk Assessment and fall within the allotted range you will automatically be awarded points. If you have a health professional measure your ab circumference you must submit the proper verification form with record of your ab circumference to the TriHealth Wellness Coordinator. If your ab circumference does not fall within the allotted range after taking the HRA; you have the opportunity to submit an updated ab circumference after the mid-point of the calendar year.

Health/Wellness Activities Incentive Program Participations

Programs offered by TriHealth (Biggest Loser, Holiday Hold, etc…). To receive credit you must complete the program and meet all requirement of each specific program. This will be outlined in the program packet for each incentive program ran by TriHealth.

Educational Activities Health Fair To receive credit you must attend and sign in at these Health Fairs organized by

TriHealth for City employees on various topics.

Nutrition Consults with Registered Dietician

To receive credit you must schedule and attend a one on one consult with a TriHealth registered dietician to give nutritional guidance.

Lunch and Learn To receive credit you must attend and sign in a the presentation given by TriHealth staff on a specific health/wellness/fitness related topic

Educational Quizzes To receive credit you must read Vitality Magazine and answer the questions on the quiz correctly. These will be offered monthly.

Physical Activities General Fitness Assessment To receive credit you must schedule and attend a general fitness assessment

consisting of 4 different exercise tests. To receive credit for an individual test, you must earn a score of average or better.

Exercise Tracking To receive credit you must complete a minimum of 12 workouts per month, have your workout verified and submit your workout log.

Walking Program To receive credit you must attend and sign in at each walk. You must attend 75% of the dates in order to receive your points.

Personal Trainer/Fitness Consultation

To receive credit you must schedule and attend a one on one consult with a TriHealth registered dietician to give fitness guidance.

Athletic League Participation To receive credit you must participate in an athletic league and submit proof of participation to TriHealth.

Community Walk/Run To receive credit you must participate in a community run or walk and submit proof of participation to TriHealth.


City of Montgomery Points Map

*Possible points based on participant age and gender

50 year old Female participant 50 year old Male participant

Wellness Measure Points Wellness Measure Points

Physical 30 Physical 30

Pap Smear 25 PSA 25

Colonoscopy 25 Colonoscopy 25

Mammogram 25 Eye Exam 20

Eye Exam 20 Dermatology 20

Dermatology 20 Dental Cleaning 1 15

Dental Cleaning 1 15 Dental Cleaning 2 15

Dental Cleaning 2 15 Flu Shot 15

Flu Shot 15

Biometrics 30 Biometrics 30

BMI 20 BMI 20

Blood Pressure 20 Blood Pressure 20

Fasting Blood Glucose 20 Fasting Blood Glucose 20

Total Cholesterol 20 Total Cholesterol 20

LDL 20 LDL 20

HDL 20 HDL 20

Triglycerides 20 Triglycerides 20

Ab Circumference 20 Ab Circumference 20

Incentive Program Participation 15 Incentive Program Participation 15



Team Outing 15 Team Outing 15


Health Fair 10 Health Fair 10


Nutrition Consult 5 Nutrition Consult 5

LNL 5 LNL 5

LNL 5 LNL 5

LNL 5 LNL 5

LNL 5 LNL 5

LNL 5 LNL 5

LNL 5 LNL 5

Monthly Logs 120 Monthly Logs 120

Monthly Quizzes 60 Monthly Quizzes 60

GFA 30 GFA 30

Cardio Score 20 Cardio Score 20

Upper Body Strength Score 20 Upper Body Strength Score 20

Flexibility Score 20 Flexibility Score 20

Core Strength Score 20 Core Strength Score 20

Walking Program 15 Walking Program 15

Fitness Consult 5 Fitness Consult 5

Athletic League Participation 5 Athletic League Participation 5

Community Run/Walk (4 total) 20 Community Run/Walk (4 total) 20

Total Points Possible 845 Total Points Possible 820

Needed for GOLD 400 Needed for GOLD 400

30 year old Female Participant 30 year old Male Participant

Wellness Measure Wellness Measure

Physical 30 Physical 30

Pap Smear 25 Eye Exam 20

Eye Exam 20 Dermatology 20

Dermatology 20 Dental Cleaning 1 15

Dental Cleaning 1 15 Dental Cleaning 2 15

Dental Cleaning 2 15 Flu Shot 15

Flu Shot 15

Biometrics 30 Biometrics 30

BMI 20 BMI 20

Blood Pressure 20 Blood Pressure 20

Fasting Blood Glucose 20 Fasting Blood Glucose 20

Total Cholesterol 20 Total Cholesterol 20

LDL 20 LDL 20

HDL 20 HDL 20

Triglycerides 20 Triglycerides 20

Ab Circumference 20 Ab Circumference 20








Nutrition Consult 5 Nutrition Consult 5

LNL 5 LNL 5

LNL 5 LNL 5

LNL 5 LNL 5

LNL 5 LNL 5

LNL 5 LNL 5

LNL 5 LNL 5

Monthly Logs 120 Monthly Logs 120

Monthly Quizzes 60 Monthly Quizzes 60

GFA 30 GFA 30

Cardio Score 20 Cardio Score 20

Upper Body Strength Score 20 Upper Body Strength Score 20

Flexibility Score 20 Flexibility Score 20

Core Strength Score 20 Core Strength Score 20

Walking Program 15 Walking Program 15

Fitness Consult 5 Fitness Consult 5

Athletic League Participation 5 Athletic League Participation 5

Community Run/Walk (4 total) 20 Community Run/Walk (4 total) 20

Total Points Possible 795 Total Points Possible 770


*Possible points based on participants screening and GFA results only or participants activity participation only

Results Based Participant Activities Based Participant

Biometrics 30 Incentive Program Participation 15

BMI 20 Incentive Program Participation 15

Blood Pressure 20 Team Outing 15

Fasting Blood Glucose 20 Team Outing 15

Total Cholesterol 20

LDL 20 Biometrics 30

HDL 20

Triglycerides 20 Health Fair 10

Ab Circumference 20 Health Fair 10

Nutrition Consult 5

GFA 30 LNL 5

Cardio Score 20 LNL 5

Upper Body Strength Score 20 LNL 5

Flexibility Score 20 LNL 5

Core Strength Score 20 LNL 5

LNL 5

Prevention 10-30 pts

Health/Wellness Activities 15 pts Monthly Logs(12) 120

Educational Activities 5-10 pts Educational Quizzes (12) 60

GFA 30

Walking Program 15

Fitness Consult 5

Athletic League Participation 5

Community Run/Walk (4 total) 20

Prevention 10-30pts

Total Points Possible 340-355 Total Points Possible 410-430


***Points must be earned in each of the 5 categories to receive a payout***


Health Screening Confirmation Form

This form is to be signed by a representative of the health care provider at the time of service and the service rendered indicated.

Examples of services for which you earn points and must be documented on this form include dental cleanings, mammogram,

comprehensive physical exam, and comprehensive eye exam by an ophthalmologist, and others as approved by program

administrator.

Patient Name______________________________________________________

Type of health care service provided:

Complete Physical

Preventive Dental Cleaning

Comprehensive Eye Exam

Wellness Screening (PSA, Mammogram, etc)

Please indicate what was performed: _______________________________________________________

____________________________________________________ ____________ Health Care Provider Signature Date Please attach receipt if applicable. Fax completed for to 513-852-3889.


Monthly Workout Log

Month: ________________________ You must complete 12 workouts per month to earn Wellness Points. A workout is defined as the following:

• A monitored workout of at least 30 minutes (Personal training, group fitness class, etc…) • 6 miles biked • 2 miles ran/walked

I herby certify that this workout information is correct and accurate. _________________________________ ______________________ Signature of Participant Date

Please submit this log within 30 days of completion (i.e., submit May workout log by the end of June. DO NOT submit all 12 months at the end of the wellness year.)

Date Type of Workout/Signature of Wellness Member 1

2

3

4

5

6

7

8

9

10

11

12


Wellness Program Waiver

I, _________________________________________, understand I am under no obligation to participate in the Wellness Program. Participation is strictly voluntary and is not part of my duties or work responsibility to the City. If I am injured during my participation in a wellness activity, the City will not recognize this injury as an on the job injury and the City will not accept worker’s compensation responsibility for such injury. Additionally, I understand such injuries are not recognizable as an occupational leave injury.

I am voluntarily participating in the Wellness Program. I understand that any activities in which I choose to participate are at my own risk. ________________________________________ ____________ Signature of employee Date

Wellness Program Waiver Policy Employees are under no obligation to participate in the Wellness Program. Participation is strictly voluntary and is not part of your duties or work responsibility to the City. If you are injured during your participation in a wellness activity, the City will not recognize this injury as an on the job injury and the City will not accept worker’s compensation responsibility for such injury. Additionally, such injuries are not recognizable as an occupational leave injury. Employees participate in the program voluntarily and employees participate in any program activities at their own risk.


Biometric Data Reporting Form

NAME: ___________________________________

• All results must be submitted to the Wellness Coordinator • All testing must have been completed between January 1 and December 31 of the current year. • Participants may resubmit numbers once per year and must include the entire panel of tests.

Return Form to: Erin Pauley | Wellness Coordinator | 513 977 0026 Email: [email protected] EFax: 513 852 3881 11129 Kenwood Rd, Cincinnati, OH 45242

Test Results Certified By: __________________________________ (Stamp of Physician or Lab)

BIOMETRIC MEASURES VALUE TEST DATE (Month/Day/Year)

SYSTOLIC BLOOD PRESSURE LEVEL (top number)

DIASTOLIC BLOOD PRESSURE LEVEL (bottom number)

TOTAL CHOLESTEROL LEVEL

LDL CHOLESTEROL LEVEL

HDL CHOLESTEROL LEVEL

TRIGLYCERIDES LEVEL

GLUCOSE LEVEL (indicate fasting or non-fasting)


Policy Number VI-8: Waiver of Workers’ Compensation Benefits and Full Release of Liability for Recreational or Fitness Activities

Purpose: The purpose of this policy is to limit the City’s exposure to workers’ compensation claims and law suits stemming from its employees’ voluntary participation in City-sponsored recreational/social activities and fitness programs and from its employees’ voluntary use of City physical fitness and recreational equipment/facilities.

Policy: The City offers recreational and social activities to its employees to encourage team-building and social experiences which are important for the development of positive relationships and productive interaction among staff. The City also offers access to recreational equipment and facilities for physical fitness training. However, participation in these activities is entirely voluntary and occurs outside of the hours of employment and/or outside of the scope and course of employment. Examples of such activities include team bowling, team outings to sporting events (Reds games and University of Cincinnati games), canoe trips, the MontyGomery Golf outing, and paintball outings.

The State of Ohio recognizes that these activities are outside of the course and scope of employment and the state provides a waiver to be signed by employees to exclude any injury from Workers’ Compensation exposure. The City also requires all participants in City recreational programs to sign waivers and releases, and a second purpose of this policy is to be consistent in administering the program between employees and the consuming public.

There are multiple ways to ensure that the City does not incur unnecessary costs in offering recreational and social activities, including limiting its exposure to workers’ compensation claims and to law suits which could arise as a result of an employee’s voluntary participation in these activities. Criteria for determining if an activity qualifies for a waiver of workers’ compensation benefits and a full release of liability are as follows:

• employee participation is voluntary,

• the activity is outside the scope of the employee’s normal job duties, and

• the activity is a recreational/social activity, a fitness program, or an activity involving the use of City recreational or physical fitness equipment or facilities.

Procedure:

1. Each employee is required to complete an Ohio Bureau of Workers’ Compensation C-159 form (Waiver of Workers’ Compensation Benefits for Recreational or Fitness Activities) and a City of Montgomery “Release, Hold Harmless and Agreement Not to Sue” form prior to participating in an activity which meets the criteria listed above. The completion of these forms includes signing and dating the forms, as well as listing the specific activity(ies) or event(s) in which the employee will be participating. The Workers’ Compensation waiver can be signed once each year and list all activities in which the employee intends to participate. The Release form must be signed for each event.

2. The individual organizing the activity or event shall provide a list of all participants along with a completed C-159 form and a completed “Release, Hold Harmless and Agreement Not to Sue” form from each participant to the Assistant City Manager at least one week prior to the date of the activity or event.

3. For employees voluntarily using City recreational/physical fitness equipment or facilities, the employee shall submit a completed Ohio Bureau of Workers’ Compensation C-159 form and a completed “Release, Hold Harmless and Agreement Not to Sue” form to the Assistant City Manager prior to utilizing said equipment and/or facilities.

4. The Ohio Bureau of Workers’ Compensation C-159 form and the City of Montgomery “Release, Hold Harmless and Agreement Not to Sue” form shall be updated by the employee and resubmitted to the Assistant City Manager periodically as determined by the Assistant City Manager and as required by provisions of ORC Chapter 4123.

Failure to comply with these procedures shall disqualify the employee from participating in the activity and may result in disciplinary action up to and including termination from employment.

Cross Reference: Policy Number V-15: Wellness Incentive Program

Release, Hold Harmless and Agreement Not to Sue

I, ________________________________________ fully understand that my participation in the

_________________________________________ (hereinafter referred to as “recreational/fitness activity”) exposes me to the risk of

personal injury, death or property damage. I hereby acknowledge that I am voluntarily participating in the recreational/fitness activity

and agree to assume any such risks.

I hereby release, discharge and agree not to sue the City of Montgomery for any injury, death or damage to or loss of personal

property arising out of, or in connection with my participation in the recreational/fitness activity from whatever cause, including the

active or passive negligence of the City of Montgomery, its agents, employees, or any other participants in the recreational/fitness

activity.

In consideration for being permitted to participate in the recreational/fitness activity, I hereby agree, for myself, my heirs,

administrators, executors and assigns, that I shall indemnify and hold harmless the City of Montgomery from any and all claims,

demands, actions or suits arising out of or in connection with my participation in the recreational/fitness activity.

I HAVE CAREFULLY READ THIS RELEASE, HOLD HARMLESS AND AGREEMENT NOT TO SUE AND FULLY

UNDERSTAND ITS CONTENTS. I AM AWARE THAT IT IS A FULL RELEASE OF ALL LIABILTIY AND SIGN IT ON MY

OWN FREE WILL.

Date: _____________________________ _______________________________________ Signature ________________________________________ Witness Signature


Wellness Program Guide - TriHealth...• Health/Wellness Activities • Biometrics B. The City will...

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