HEART HEALTHYEVENT REQUEST FORM

Please complete this form prior to requesting onsite wellness events at your department. Questions about completion of this form may be directed to HSS Wellness Team. Events must be requested at least 6-8 weeks in advance. Please send all completed forms to .

SECTION 1: TYPE OF EVENT Please select the event you are requesting by clicking the appropriate box.

AWARENESS ACTIVITY (select 1)

☐ / Advanced Biometric Screening / ☐ / Basic Biometric Screening
This event will include:
  • Cholesterol, Glucose (fingerstick blood draw)
  • Blood Pressure, Body Mass Index (height, weight), Body Fat %
/ Please select which screening(s) you would like to offer.
☐ Blood Pressure ☐ Body Fat %
☐ Waist Circumference ☐ Body Mass Index (height, weight)

PROGRAMS (select 1, 2 or 3)

☐ / Goal Setting with a Wellness Coach / ☐ / Seminars: All seminars are 45 minutes. Please choose 2-3. / ☐ / Series
This activity includes bringing a wellness coach onsite 4-8 hours to provide individual 20-minute appointments to review the results from a biometric screening event and set personal goals around health and well-being. / Peace of Mind
☐Managing Stress
☐Balancing Work and Family
☐Managing our Emotions
☐Overcoming Anxiety
☐Dealing with Difficult People
☐Creating Happiness
☐Conquering Negativity in the Workplace
☐Getting Healthy Sleep
☐Tai Chi
☐Qi Gong / Prevention
☐Getting Ready to Quit Tobacco
☐Find Your Passion, Find Your Health: Making Behavior Change Work for You
Movement
☐Get Moving
Nutrition
☐Healthy Weight: Setting Yourself
Up for Success
☐Understanding Your Metabolism
☐ Healthy Eating for You
☐ Nutrition for Vitality / Peace of Mind
☐UCSF Stress Management and Resiliency Training workshop (2 hour training)
Wellness Coaching
☐Employees choose their own personal wellness goals and work with a coach to reach them during 3 sessions that take place over 6 weeks (every other week).
Prevention
☐Freedom from Tobacco Series (7, 2-hour sessions)
Nutrition
☐Healthy Weight
(Series – 10 sessions total of 25 hours)

CULTURAL COMPONENTS (select 1, 2 or 3)

☐ / People / ☐ / Policy / ☐ / Place
Heart Healthy Voting / Heart Healthy Meeting Activities / Heart Healthy ZoneCommitment Cards #of cards requesting:______

SECTION 2: EVENT DETAILS Please complete the below for awareness and program activities. Answer all questions in the gray shaded field in the events table below.

Requester Information / Event 1 / Event 2 / Event 3
Name
Email
Phone Number
Event Partnership Details
Are you currently partnering with other Wellness Champions for your event?
Please list name(s) of partnering Champions
Event Specifics
Requesting Department Name
Expected Participation
Preferred Date(s) and Time(s) (1st Choice)
(Please include start and end time. If requesting a series please include all dates and times the series will take place)
Alternate Date and Time (2nd Choice)
(Please include start and end time. If requesting a series please include all dates and times the series will take place)
Address, City, State, Zip
Room and Room Location
(i.e. Conference Room A, 2nd floor)
Indoor or Outdoor Location?
Room Details
(capacity/private room/shared space)
Parking (Please describe where our staff can park)
Available Technology
Which of the following are in the room or can be provided by the onsite contact? (Computer, projector, internet access, power source, extension cord, audio, etc.)
Day-of Event Contact
Enter “same” if same as requestor information
Name
Email
Phone Number
(Include cell phone where available)
Scheduling Tool
Which scheduling tools will you use for sign up’s (Online schedule tool or paper)?