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C�TY OF ROSEVILLE WELLNESS PROGRAM 2005 <br />Even�ITopic Verification Points <br />HEALTHY LIFESTYLE - W4RK�LI.��I��ALTH/W�LL-I3ElNG <br />DID NOT USE ANY SICK LEAVE THIS TRIMESTER? Payroll signature: ❑C� <br />I reviewed a self help or self care book, health update, employee newsletter and used <br />something from it, on yourHonar.• I� <br />Do you consistently watch less than 14 hours of TV a week? on Yourxonor.� ❑ <br />I completed HP "Partners in Quilting" or other smoking/tobacco cessation program. Programreceiptalfached: �1C7❑ <br />I am tobacco free. pa Yourxonor: �I <br />Maintain a personal �7�alih journal that includes exercise and diet, on YourHonor ❑ <br />Used the nurse line or did online research rather than an office visit on a minor issue? on YourNonor.- C.,] <br />Accessed EAT'. On YourHonor ❑ <br />TOTAL HEALTHY LIFESTYLE - WO�i�C/Li�'�/��ALTHIWELI..-B�ING <br />11 ����I� � � � <br />I HEALTHY LIFESTYLE - SAFETY <br />Wear seat belt daily on YourNonor. O <br />Completed training course other than the OSHA required training (personal safety, <br />defensive Driving, CP�t/FirstAid, Defibrillator) RegisfratianFormAlfached: C1�I <br />Do you wear protective gear such as krtee�ads, helmets etc, when biking, motorcycling, <br />skateboard, inline skating or other sports? on Your Honor, C� <br />1 have been injury free this trimester and stretch daily or a�er every workout, on YourHonor. C� <br />I keep my home secured when I am there and when I am not, on yvurHonor.� C] <br />I lock my car doors when I am not in it and when I am traveling? on YourHonor, C <br />TOTAL HEALTHY LIFESTYLE - SAFETY ( 7 POSSIBLE ) <br />PROGRAMSI ACTIVITIES <br />Participated in weight management program (i,e. Weight Watchers, LA Weight Loss). receiptaftacherl p�] <br />Participated in 10,000 Steps Program thru Health Partners. receiptat�ach�d f� <br />A,ttended health related seminar, workshop, presentation. Presenters Signature: C] <br />TOTAL �'ROG�ttAMS/ ACTIVITIES ( 4 POSSIBLE ) <br />EDUCATION <br />Invited a soeakerloresenter and organized a lunchtime vresettCat€on. (see I-��i. before doing <br />this one). Cor7imiff��ChairSignature; O� <br />Provided a new idea for the ����rtess Program that was adopted by the Health &Bene�ts <br />Committee. (Give idea to 7-��). Cvmmitfee Chair signature: � C7 <br />Provided Health & Benefits er�aiU�newsletter information to Communication's Specialist <br />outside Of regular WOrk h0urs communication's Specialist signature: (� <br />�Purchased health related equipment, videos, books, eta (receipt required, $20 minimum) �`-`•�`�'�atiached p <br />TOTAL EDUCATION (6 POSSIBLE } � <br />. T�I�,r1E�-EF. <br />� �3•:r::��:'IL'-= 'r','t�? '•E�� Vt:�hJT= F::�? �=F1�- S:S� ��P,;''� I��T,�LS <br />hf•�si uan i�� ¢ri ir: ii i i �ir �f 3�; �::�I t7ti5 IR � rr� r.i ESkCr 1:� ri �r��i Mc tl ic I I IL'L'� i Lr: C�" �� �•�� ��{� �,�' <br />�h�ice or� �he V4e�lr�a�� Incen�3+�e Gha��ei ��rrr� �or �ltiar trirn�ster. �9 ��ssrbl� �or�t� <br />Em lo eeSi nature: Tod� 's Date: <br />Points A roval Si nature: <br />C;�boCUments and Seitingslcarolyn.curtilLocaf 5ettingslTemporary Internet F��]LI�#�'�W�s Program Activiiiesiraeking Fi�jB E�S� 2 <br />