Program Materials

 

Activity Verification Form

 

Participant’s Name ___________________________________________            Date(s) Completed  __________________

 

Activity ___________________________________________________            Point Value for the Activity ____________

 

Detailed Description of the Activity:

 

 

 

 

I hereby verify that the completed activity described above and the information on this form is correct to the best of my knowledge.

 

________________________________________       ________________

Participant’s Signature                                                                           Date

Seatbelt Commitment Form

 

I,                                                        , do commit to wear my seatbelt 100% of the time while traveling in a motor vehicle.  I understand that wearing a seatbelt can protect me from injury or death in the event of an accident and I am making this commitment to safeguard my well being.

 

Signed:                                                                                         

 

 

Date:

 

Slip and Fall Commitment Form

 

                   I,                                                  , do commit to practice active slip and fall precautions 100% of the time while I am performing my duties at work.  These precautions include all of the following:

1. Use a ladder instead of a chair

2. Pay attention to my surroundings (water on the floor, boxes or electrical cords in your walking area).

3. Use a handrail when walking down the stairs.

4. Pick up heavy items appropriately (bended knees and back straight)

5. Report my injury to my supervisor immediately.

6. If injured and the injury requires more than first aid, I will use the clinic designated by my supervisor.

 

Signed:                                                                Date:

 

Sleep Log for Months __________________ And _______________

 

Fill in the above calendar with the correct dates for the months you are logging.

Record the amount of sleep you receive each night on the calendar. 

In order to receive one point in the Wellness Points Incentive Plan you must receive 7 to 8 hours of sleep for at least 5 nights per week. 

You may complete this log twice, for a total of two points in the incentive plan.

 

I hereby verify the information above is accurate and honest to the best of my knowledge.

Participant’s Signature:                                                            Date:

Physical Activity Log

Name:

 

Starting Date_____________________________ End Date______________________________

Set a weekly goal for the amount of physical activity you will do each day.

Record the amount of physical activity you perform each day.

In order to receive one point in the Wellness Points Incentive Plan you must do 30 minutes of activity 3 to 5 days per week.

 

I hereby verify the information above is accurate and honest to the best of my knowledge.

 

Participant’s Signature:                                                                                                                         Date:

 

Fruit and Vegetable Log

Name:

 

Starting Date____________________________  End Date_________________________________

Set a weekly goal for the amount of daily fruits and vegetables you will eat.

Record the amount of fruits and vegetables you eat each day.

In order to receive one point in the Wellness Points Incentive Plan you must eat a total of 5 fruits and vegetables each day.

 

I hereby verify the information above is accurate and honest to the best of my knowledge.

 

Participant’s Signature:                                                                                                                         Date:

Molton, Allen & Williams provides employees with peace of mind by tracking all points for the employer. We only provide the employer with the names of employees who have earned the incentive. We do ask that the employee makes a copy of the completed log and keeps the original for their records, and send the copy to:

 

Molton, Allen & Williams, LLC

ATTN: Natalie Nelson or Sarah Smith

1000 Urban Center Drive, Suite 400

Birmingham, AL 35242

Fax: (205)969-5043