Certified Wellness Tax Credit Program Application

Please complete the following information as thoroughly and accurately as possible:

(Click the name of the field you would like to complete; for example: clicking “Name of Business” will allow you to complete information in the “Name of Business” text field.)

Name of Business: Company XYZ

Address: 1234 Main St., Wellness, IN 12345

County: Healty

Phone Number: 123-456-7890

Fax Number: 123-456-7899

Contact Person: John Doe

Title: Manager

Number of Employees: 55

Type of Business: Healthy Business

How long have you had a wellness program?

3 years

What is your company’s mission and/or vision statement?

Our company's mission/vision statement is…

In what capacity is your wellness plan a part of your business?

Our wellness program plays an integral role in our company's culture because…


ssesments:ropriate Weight Loss Wellness Plan:

your business?______Outline of Requirements for the Wellness Plan

Employee Appropriate Weight Loss:

(Please describe in detail the assessments, educational materials, rewards programs, and measurement tools)

Assessments:

* Annual health risk assessment (HRA) provided by a trained professional that identifies
employees' needs and readiness to lose weight and/or maintain a healthy weight (whichever is
applicable)

Intervention/Education:

* Annual health screening conducted by a trained professional with biometric data that includes
height, weight, waist/hip ratio, and body fat composition to help keep track of weight loss or
maitenance of a healthy weight
* Healthy snacks, such as fresh fruits and vegetables from the Farmers Market in the company
break room
* Catering standards adopted to ensure that healthy options are present when the company
purchases food for employees
* Monthly wellness newsletter with healthy recipe included
* Consultations with a health coach/health educator following annual health screening
* Walking and other physical activity challenges/contests constantly being held
* Access to American Heart Association, Mayo Clinic, American Cancer Society, Centers for
Disease Control, and the National Institute of Health websites with additional materials on
fitness, nutrition, and weight loss provided
- these materials include nutrition guides, meal planners, healthy recipes, food journals, etc.

Rewards Program:

* Rewards such as gift cards, Farmers Market vouchers, new walking/running shoes, bicycles
and other health and fitness related items are offered to employees who win or demonstrate
effort, initiative, attendance, participation, and completion of annual health screenings and
other physical activity contests/challenges
* Pedometers are available to employees at no cost as an incentive to join walking
contests/challenges

Measurement Tools:

* Comparative results using an annual aggregate data report to look at employee weight and
other above mentioned biometric markers, as well as behavior change
* Collect employee testimonials and surveys quarterly to determine how the program is being
received, as well as to help us mold the program to fit our employees' needs

Smoking Cessation:

(Please describe in detail the assessments, educational materials, rewards programs, and measurement tools)

Assessments:

* Annual health risk assessment (HRA) provided by a trained professional that identifies
employees's needs and readiness to quit smoking or sustain from tobacco use (whichever is
applicable)

Intervention/Education:

* A no smoking/tobacco use policy has been enforced on the company's property
* Election data (smoker/nonsmoker rates) from health plan
* Wellness library that includes smoking cessation pamphlets and referral sources
* Free 24/7 access to tobacco quitlines, nicotine replacement therapy, and tobacoo counselors
* Access to American Cancer Society and Indiana Tobacco Prevention Coalition websites, as
well as free pamphlets and referral sources to help our employees quit using tobacco products

Rewards Program:

* Rewards such as gift cards, Farmers Market vouchers, and a discount on the employee's health
care plan are offered to those who quit using tobacco products or demonstrate effort, initiative,
attendance, participation, and completion of such programs

Measurement Tools:

* Comparative results using an annual aggregate data report to look at tobacco use among
employees, as well as behavior change
* Collect employee testimonials and surveys quarterly to determine how the program is being
received, as well as to help us mold the program to fit our employees' needs

Pursuit of Preventative Health Care Services:

(Please describe in detail the assessments, educational materials, rewards programs, and measurement tools)

Assessments:

* Annual health risk assessment (HRA) provided by a trained professional that identifies
employees' needs and readiness to change, pertaining to preventative care

Intervention/Education:

* Annual health screening conducted by a trained professional with biometric data that includes
total cholesterol, HDL, LDL, cholesterol ratio, glucose, triglycerides, blood pressure, heart
rate, bone density, and prostate-specific antigen (PSA) tests
* Consultations and health coaching/counseling provided by a trained professinal that educate
employees on the results of their annual health screenings and how to manage chronic diseases
and other health concerns
* Sharps containers are provided in each bathroom
* Have a designated lactation room for mothers
* Employees are provided the option of a flu vaccination annually at no cost to them
* Bimonthly wellness newsletter including an overview of the wellness program and a calendar
with screening dates, "Did You Know?" health facts, monthly health awarenesses and
information related to health fairs and clinics
* Access to American Heart Association, Mayo Clinic, American Cancer Society, Centers for
Disease Control, and the National Institute of Health websites, as well as pamphlets with
gender specific preventative care education are provided at no cost to employees
* Employees are allowed 20 minutes each day, during work hours, to use for additional health
related activities

Rewards Program:

* Rewards such as gift cards, Farmers Market vouchers, new walking/running shoes, bicycles,
and other health related items are offered to employees who demonstrate effort,
initiative, attendance, participation, and completion of annual health screenings and other
activities related to their overall health and well being
* Pedometers are available to employees at no cost as an incentive to join walking
contests/challenges

Measurement Tools:

* Comparative results using an annual aggregate data report to look at overall employee health
and other above mentioned biometric markers, as well as behavior change
* Collect employee testimonials and surveys quarterly to determine how the program is being
received, as well as to help us mold the program to fit our employees' needs

Additional Information:

(Please feel free to provide any additional information about your wellness plan on below. Remember: attachments will not be accepted with your wellness program application.)