Success Story Consent Form

Form Approved
OMB No. 0920-XXXX
Exp. Date: XX-XX-XXXX

CDC National Healthy Worksite Program (NHWP)
Success Story Consent Form
Public reporting of this collection of information is estimated to average 10 minutes per response, including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is
not required to respond to a collection of information unless it displays a currently valid OMB control number.
Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74,
Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Informed Consent
Before you get started, we’d like need to give you some more information to help you decide whether or not you
would like to participate.
•

•
•
•
•

•
•
•

This project is funded by the Centers for Disease Control and Prevention. Many parts of the project are
being managed by Viridian Health Management (Viridian). Viridian is a private health and wellness
company based in Phoenix, AZ. Viridian provides flexible, customized solutions to building comprehensive
healthy worksite programs. They are helping CDC implement the National Healthy Worksite (NHW)
program.
You were asked to participate because your worksite is participating in the National Healthy Worksite
(NHW) program as a benefit to employees.
Your participation in program communications is voluntary. In the course of completing this form, you may
refuse to answer specific questions. You may also choose to end completing the form at any time.
The form is designed to take about 10 minutes.
All of the comments you provide will be maintained in a secure manner. We will not disclose your
responses or anything about you unless we are compelled by law. In our program communications, your
name or image will not be linked to the comments you provide unless you authorize us to do so.
CDC is authorized to collect information for this project under the Public Health Services Act.
There are no personal risks or personal benefits to you for participating in this discussion.
We are interested in your comments so that we can improve the NHW program for future participants.
Please feel free to contact [INSERT WORKSITE NHWP PROGRAM MANAGER]. [HIS/HER] number is
[INSERT TEL #]. You can also call Viridian Health Management toll-free at 1-877-486-0140.

Instructions
When you have completed this form, please give it to [INSERT WORKSITE NHWP PROGRAM MANAGER]. If
you have any questions, Please feel free to contact [INSERT WORKSITE NHWP PROGRAM MANAGER].
[HIS/HER] number is [INSERT TEL #].

1

Authorization to Use Personal Information
Employee’s Name: ____________________________________

Date of Birth: _______________

Previous Name:_______________________________________

ID #:_______________________

I request and authorize Viridian Health Management, LLC to use my personal / healthcare information that I
disclose and my photo as part of the National Healthy Worksite Program (NHWP) communications.
My information and image will be distributed as follows:
Website URL:
Printed communications
Email communications
Other (please describe):
The image
will NOT be distributed externally
will be distributed externally as follows:_________________________________________________________
Project Description / Purpose____________________________________________________________________
Employee Signature: ___________________________________________

Date Signed:_______________

Viridian Health Management Signature:____________________________

Date Signed:_______________

Please return this form with all signatures to:
Viridian Health Management, LLC
22601 North 19th Avenue, Suite #240
Phoenix, AZ 85027
For Internal Use Only
Date received:_______________
Approval Date: _____________
Approval Signature:____________________________________

2