Health Screening Consent / Contact Form

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

Employee Health Screening Consent / Contact 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.
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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 W orksite (NHW) program.
You were asked to participate because your worksite is participating in the National Healthy W orksite (NHW)
program as a benefit to employees. All employees at your worksite will be asked to complete this health
screening consent/contact form at the beginning and at the end of the NHW program.
Your participation in this health screening is voluntary. You may choose not to participate or end the health
screening at any time.
Completing the health screening consent/contact form is designed to take about 10 minutes.
All of the information you provide will be maintained in a secure manner. W e will not disclose your information
or anything about you unless we are compelled by law. Your information will be combined with other
information we receive and reported in the aggregate as feedback from the group. In our project reports,
your name will not be linked to the comments you provide in this discussion.
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
To make sure that health-related information and programs are tailored to affect your health problems
and concerns, we are asking each employee to fill out this consent/contact form.
If you have any questions, Please feel free to contact [INSERT WORKSITE NHWP PROGRAM MANAGER].
[HIS/HER] number is [INSERT TEL #].

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Participant Information:
Company Name:

Location:

Last Name

First Name

Middle/2nd Name

Participant’s Date of Birth (mm/dd/yyyy)

Best Phone Number to Reach You:

Alternate Phone Number (home, work, cell)

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Email Address

FOR OFFICE USE ONLY - Do not complete below this line
Participant / Member ID

REQUIRED CLINICAL INFORMATION

Height

TO BE COMPLETE BY CLINICAL STAFF AT ONSITE SCREENING EVENT

FEET

INCHES

Fasting Status

Fasting
Non-Fasting
Unknown ___

Weight

LBS

Total Cholesterol

mg/dL

Waist Measurement
Pulse Rate

INCHES

HDL
Triglycerides

mg/dL
mg/dL

LDL Cholesterol

mg/dL

Blood Pressure
Body Mass Index
(BMI)

BPM

/
(SYSTOLIC /DIASTOLIC)

TC / HDL Ratio
Glucose

-------------------------------------------------------------------------------------------Technician Name
Date
Time

mg/dL

Referred to MD

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Employee Informed Consent
Biometric Screening and Health Assessment
You are being asked to participate in a program called the National Healthy Worksite (NHW) Program.
This project is funded by the Centers for Disease Control and Prevention (CDC), a federal government
agency that is funding this project because research has shown that workplace wellness programs can
positively affect employee health. The goal of this program is to learn more about the effects of workplace
health promotion policies, practices, and culture on the health and well-being of employees. About 15,000
employees from multiple employers across the country will participate in this project. The number of
employees participating may vary at each work site.
Who is providing the worksite health program?
Viridian Health Management is implementing the workplace programs and collecting data, in
collaboration with the University of Connecticut Health Center. Research Triangle Institute International, a
non-profit research organization, is conducting a national evaluation of the NHW program.
Why am I eligible to participate?
Your employer has agreed to be a part of the NHW program. Your participation is very important to
this project because no one else in the organization is exactly like you. We would like you to consider
participating in all wellness program activities offered by your employer.
What do I have to do to be part of this project?
Participation in the study is completely voluntary and you can stop at any time. The National
Healthy Worksite program has 3 parts. For Part I of the program, we ask you to take part in health screening
that includes some biometric screening tests and questions about your health and health habits.
For the biometric screening, we will:
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Take your blood pressure and pulse using a manual blood pressure method (blood pressure cuff,
stethoscope, and sphygmomanometer)
If you are able to stand unassisted, measure your height while you are standing
If you are able to stand unassisted, ask you to stand on a scale to measure your weight
Use a finger prick to obtain a small blood sample to obtain a lipid profile and blood glucose
If you are able to stand unassisted, measure your waist circumference with a flexible tape measure

The biometric screening and health assessment will take approximately 30 minutes and most people find it
very interesting
Will you tell me the results of my biometric screening?
At the end of the biometric screening, you will receive all of your testing results with an explanation of
each result. After completing the health assessment, you will receive a personal report which explains your
results. You will have the opportunity to discuss your results with a health coach.

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How are privacy and security maintained?
The National Healthy Worksite program is strongly committed to safeguarding the information you
provide to us. Your name will be replaced with a number for the purposes of evaluating program results. Your
personal information will not be shared with your employer. Information will be combined with data from
other participants in the program and only group results will be reported. Your individual data will also be
shared with Viridian Health Management health coaches to provide individual health coaching interventions
specific to your current health status and lifestyle habits.
What are the benefits of participating in the National Healthy Worksite program?
You may benefit from learning more about your health. You will receive a card with your blood pressure
and BMI results and information on what they may mean. You can show the results to your doctor for followup questions. This is an opportunity for you to make a valuable contribution to your workplace. The results of
this program will describe the health and well-being of employees and their families, and will also provide
valuable information about your workplace culture.
What are the potential risks involved in participating?
The risks related to participating in the basic health measures and health assessment are minimal. It is
possible that some of the questions in the health assessment may make you feel slightly uncomfortable, but
you can skip any questions you don’t want to answer. You may also learn that you are at risk for a future
health condition, which you may prefer not to know.
How can I learn more about the National Healthy Worksite Program?
If you have any questions about this program, please call 1-877-486-0141. You can also e-mail us at
[email protected].

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CDC National Healthy Worksite Program Consent Form
I voluntarily consent to participate in National Healthy Worksite Program, a worksite wellness program which
is being conducted by Viridian Health Management. I understand that this program includes health
screenings, health assessments, and individual and group health coaching and education. The health
screenings and health assessments include biometric screening tests. I understand that a blood sample is to
be withdrawn by fingerstick and I have been made aware of the possible risks associated with this, including
but not limited to, the risk of infection, discomfort, and bruising. I understand that the explanations that I
receive may not be all-inclusive and that other, more remote risks may be involved. However, the information
that I have received is sufficient for me to consent and authorize the collection of the blood specimen.
I understand and consent to additional biometric screening tests by Viridian Health Management listed on the
reverse side of this form.
I understand that Viridian Health Management will have access to my health screening results and other
health status and lifestyle behaviors obtained through the health assessment. These results may be used to
refer you to a healthcare professional, contact you for follow up, and health coaching. I understand that my
individual results are confidential, and will not be shared with my employer. Group (summary) statistics may
be used for reporting. No other individual or entity will have access to my individual test results without my
authorization or as allowed by law.
Viridian Health Management will provide the health assessment results to me at the time of my health
screening. The health assessment results that I receive are for informational purposes only and are NOT a
medical diagnosis. It is my sole responsibility for initiating any follow up examination with my doctor to discuss
any questions, to have the meaning of any test explained, to review and interpret my health assessment
results and to obtain medical advice. Viridian Health Management has no such responsibilities.
I have received a copy of the Health Insurance Portability and Accessibility Act (HIPAA) Notice of Privacy
Practices and Employee Informed Consent. I know I can get additional information from Viridian Health
Management by calling 1.877.486.0141.
I release Viridian Health Management from any and all liability arising from the collection of my biometric
screening tests and the reporting of information concerning such analysis by Viridian Health Management.
I, the participant named below, have read, understood, and agree to the terms of this National Healthy
Worksite consent form. No attempts by the participant to modify or amend this form will change its terms in
any way be binding upon Viridian Health Management.

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Participant’s Signature:

Date:

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